National Academies Press: OpenBook
« Previous: Consequences of Unintended Pregnancy
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

4
Patterns of Contraceptive Use

Chapters 2 and 3 summarized the demography of unintended pregnancy and its consequences. The composite picture that emerges is that unintended pregnancy is common in the United States and that much would be gained if a higher proportion of pregnancies were intended at conception. This surely is not a new thought, nor is it particularly controversial.

The complexities begin to mount, however, when the next issue is approached—namely, understanding why there are such high rates of unintended pregnancy in the United States. What is it about our culture, our education and values, our methods of contraception, or our health care system that produces the patterns described in Chapter 2. This is more than a rhetorical question. It is, in fact, the essence of the challenge for policy leaders and others who are searching for ways to decrease the proportion of pregnancies that are unintended.

The direct cause of unintended pregnancy, of course, is sexual activity accompanied by contraceptive misuse, failure, or nonuse altogether. Accordingly, this chapter explores patterns of contraceptive use as they bear on unintended pregnancy. Trends in the use of different contraceptive methods are discussed, including both sterilization and reversible contraception. A discussion of contraceptive use among men is also included, covering use at first intercourse as well as at different stages of the reproductive life span; this discussion is followed by commentary on so-called dual-method contraception—that is, the use of two methods of contraception simultaneously. The chapter also includes with a brief discussion of the intersection of unintended pregnancy with sexually transmitted diseases (STDs). The next three chapters, Chapters 57, consider the many factors that influence contraceptive use and therefore the occurrence of unintended pregnancy.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Patterns of Contraceptive Use and Unintended Pregnancy

In 1988, there were more than 3 million unintended pregnancies in the United States. Slightly fewer than half of these unintended pregnancies occurred among women who reported using reversible contraception, and slightly more than half among women who reported not using contraception despite no apparent intent to become pregnant (Harlap et al., 1991). In absolute numbers, this means that, in 1988, approximately 21 million women who reported using reversible methods of contraception experienced 1.5 million unintended pregnancies. And approximately 4 million women who reported that they were not actively seeking pregnancy and not using contraception at the time that they became pregnant experienced an additional 1.7 million unintended pregnancies (Mosher, 1990).

Figure 4-1 was developed to help provide a better understanding of this complicated connection between contraceptive use and unintended pregnancy. Using data from the National Survey of Family Growth (NSFG), this figure shows that in 19881 there were approximately 58 million women of reproductive ages 15–442 in the United States (Tier 1). Six out of 10 of these women reported using contraception; 4 out of 10 reported that they were not currently using contraception (Tier 2). The women who reported using contraception are divided into two groups: those who relied on contraceptive sterilization, either their own or their partner's (Group A), and those who used reversible contraception (Group B). Of these two groups, only the women in Group B have an appreciable risk of becoming pregnant unintentionally, inasmuch as sterilization is so effective.

Similarly, women who reported that they were not currently using contraception are divided into two groups. The first—Group C—is comprised of women who were currently sexually active (i.e., they reported having had

1  

As this volume was being completed, data on contraceptive use from the 1990 National Survey of Family Growth (NSFG) telephone reinterview survey were published (Peterson, 1995). These data are used sparingly through this chapter because of concerns about the response rates among some subpopulations.

2  

This number is slightly different from the comparable number in Table 2-1 which is for 1990, not 1988, and includes 13- and 14-year-old girls. Data from 1988 (which exclude 13- and 14-year-olds) are used here because this chapter relates contraception to unintended pregnancy, and 1988 data on unintended pregnancy are more complete than 1990 data.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Figure 4-1

Contraceptive status of women experiencing unintended pregnancies, 1988. As noted in Chapter 2, the best available estimate of the pregnancies that are unintended is 57 percent. This estimate is based on the 1988 NSFG and supplemented by abortion data from 1987 compiled by The Alan Guttmacher Institute and the Centers for Disease Control. Sources: Harlap S, Kost K, Forrest JD. Preventing Pregnancy, Protecting Health: A New Look at Birth Control Choices in the United States. New York, NY: The Alan Guttmacher Institute; 1991; Mosher WD. Contraceptive practice in the US, 1982–1988. Fam Plann Perspect. 1990;22:198–205.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

intercourse in the 3 months before the survey interview),3 were fertile (neither they nor their partner had been contraceptively sterilized and they did not believe they were infertile for other reasons), and were not pregnant, postpartum, or trying to conceive. That is, they were clearly at risk of experiencing an unintended pregnancy because they used no contraception, but at the same time, they report that they were not actively planning for, or desiring, a pregnancy at that time. The other group, Group D, includes women who were not using contraception, but who were highly unlikely to experience an unintended pregnancy. These women were sterile for noncontraceptive reasons, sterile for reasons other than surgery, already pregnant or in the immediate postpartum period, trying to conceive, had never had intercourse, or were not currently sexually active (Mosher, 1990).

Thus, unintended pregnancy derives almost entirely from two groups. It occurs among women using reversible contraception (Group B), because contraceptive methods may fail or be used improperly, as discussed later in this chapter. It also occurs frequently among the relatively small group of women using no contraception who nonetheless are not actively seeking pregnancy (Group C), simply because sexual intercourse without the protection of contraception often leads to pregnancy.

Table 4-1 shows how women who do not intend to become pregnant are distributed between Groups B and C, according to several demographic variables. The table shows, for example, that among all sexually active women ages 40–44 who do not intend to become pregnant and who are not contraceptively sterilized, almost one-fourth (23.8 percent) use no contraceptive method, a finding that helps to explain the high rates of unintended pregnancy observed among older women.

It is important to stress, however, that women typically move back and forth between these two groups, making the distinction between them one that only applies at a given point in time. In particular, the category of contraceptive nonuse (Group C) includes a wide variety of women. It clearly includes women who consistently use no contraception over months or even years, many of whom have experimented with nonuse, have not become pregnant, and have gradually come to believe that they are subfecund—and in fact sometimes are. But it also includes women exhibiting only occasional periods of nonuse. Indeed, the majority of women in this nonuse category have used contraception at some previous time (Forrest, 1994b). For example, a woman may use a reversible method for a year and then, for a variety of reasons, stop using it for several moths, perhaps intending to try a different method shortly. This is illustrated

3  

This definition of sexual activity is slightly more constrained than the definition in Chapter 2, in that it includes only those women who are currently sexually active, not those who have ever had sexual intercourse.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

TABLE 4-1 Sexually Active Women Who Reported No Intent to Become Pregnant, and Were Either Using Reversible Contraception (Group B), or Not Using Contraception (Group C), by Age, Marital Status, and Poverty Level, 1988a

 

Percentage of Women

 

 

Characteristics

Reversible Contraception (Group B)

No Contraception (Group C)

Total

Total

84.7

15.3

100.0        

Age

 

 

 

15–19

78.5

21.5

100.0

20–24

87.0

13.0

100.0

25–29

86.8

13.2

100.0

30–34

87.2

12.8

100.0

35–39

84.3

15.7

100.0

40–44

76.2

23.8

100.0

Marital Status

 

 

 

Never married

80.2

19.8

100.0

Married

89.4

10.6

100.0

Formerly married

84.5

15.5

100.0

Poverty level

 

 

 

<100%

71.1

28.9

100.0

100–199%

82.1

17.9

100.0

>200%

88.2

11.8

100.0

 

a  

The denominator for these percentages is women who reported that they did not intend to become pregnant minus women who reported that they used contraceptive sterilization (i.e., all of the women in Groups B and C, but not those in Group A).

SOURCE: Forrest JD. Contraceptive use in the United States: Past, present and future. Adv Popul. 1994a;2:29–48.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

by the finding that 28 percent of contraceptive-using married women discontinue their contraceptive method during any given year without the intention of becoming pregnant. Approximately 50 percent of these women immediately switch to another method of birth control, and the other half go through a period of contraceptive nonuse (Grady et al., 1988; Henshaw and Silverman, 1988). Of course, even temporary nonuse may result in an unintended pregnancy, especially if the nonuse interval is extensive.

From a practical point of view, however, it is important to recognize that unintended pregnancy results both from spells of contraceptive nonuse and from contraceptive failure or misuse, and that the strategies needed to reduce the incidence of unintended pregnancy in each of these two groups may well be different. For example, encouraging women who are currently using contraception (Group B) to be even more careful with their methods of contraception or to use more effective methods (e.g., to switch from foam to oral contraceptives) will be quite a different task from helping a woman to confront the risks of being sexually active, not desiring pregnancy, and using no contraception at all (Group C).

Unintended Pregnancy Among Women Using No Contraception (Group C)

As shown in Figure 4-1, only 6.7 percent of women of reproductive age can be described as not intending pregnancy, yet not using contraception. This small group (Group C) contributed a full 53 percent of all unintended pregnancies in 1988, demonstrating how risky it is to engae in sexual intercourse without contraception when pregnancy is not being actively sought. Table 4-2 highlights the demographic attributes of the women in Group C. It reveals, among other things, that contraceptive nonuse is seen among women of all ages.

Nonuse among teenagers merits an additional comment. Some portion of this phenomenon reflects the common experience of having used no contraception at first intercourse, which is related to the age at first intercourse. The age of first intercourse has declined in recent years: higher proportions of adolescent men and women reported being sexually experienced at each age between the ages of 15 and 20 in 1988 than in the early 1970s. The percentage of women who had had intercourse before their 18th birthday rose from 35 to 56 percent during this time period; for men the percentage increased from 55 to 73 (The Alan Guttmacher Institute, 1994; see also Laumann et al., 1994). This is significant for unintended pregnancy because the younger the age of first intercourse, the less likely that contraception will be used at that first intercourse or in the months directly following the event. Again, though, as shown in Table 4-2, the majority of nonusers are not adolescents.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

TABLE 4-2 Sexually Active Women Who Reported No Intent to Become Pregnant and Were Not Using Contraception (Group C), by Age, Marital Status, Poverty Level, and Race and Ethnicity, 1988a

Characteristics

Percentage

Age

 

15–19

20.6

20–24

20.1

25–29

21.1

30–34

15.2

35–39

11.5

40–44

11.5

Total

100.0

Marital Status

 

Never married

52.1

Married

33.7

Formerly Married

14.2

Total

100.0

Poverty Level

 

<150%

38.2

150–299%

23.5

>300%

38.3

Total

100.0

Race/ethnicity

 

White

61.1

Black

19.7

Hispanic

13.8

Other

5.4

Total

100.0

 

 

a  

The denominator for these percentages is sexually active women who reported not intending to become pregnant and not using contraception.

SOURCE: National Center for Health Statistics. Unpublished tables from the 1988 National Survey of Family Growth. Tables 1-1, 1-2, 1-4, and 1-6 for 1988.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Unintended Pregnancy Among Women Using Contraception (Groups A and B)

Women who report using contraception—a much larger group than those who do not—also experience unintended pregnancy and, as noted in Figure 4-1, contribute nearly half of all unintended pregnancies. Unintended pregnancies occur almost exclusively among women reporting use of reversible contraception (Group B). Women who have been sterilized for purposes of contraception or who are relying for protection against pregnancy on their partner's sterilization (Group A) contribute virtually not at all to the pool of unintended pregnancy. Nonetheless, it is important to note several aspects of this group because so many women and couples rely on sterilization to prevent pregnancy, particularly in the later phases of the reproductive life span.

Contraceptive Sterilization

Nearly 40 percent of all women who report using contraception relied on contraceptive sterilization (either their own or their partner's) to avoid unintended pregnancy in 1988. Female sterilization is used much more frequently than male sterilization. Although male and female sterilization rates were nearly equivalent in the 1970s, by 1988, 28 percent of women using contraception relied on female sterilization and only 12 percent relied on their partner's use of vasectomy (Mosher and Pratt, 1990). The 1990 NSFG telephone reinterview survey and the 1992 and 1994 Ortho Birth Control Studies indicate that heavy reliance on sterilization has continued into the early 1990s, and female sterilization has continued as the predominate form (Forrest and Fordyce, 1993; Ortho Pharmaceutical Company, 1994; Peterson, 1995).4

Several factors probably account for the growing preference for female rather than male sterilization, despite the fact that the male sterilization procedure is safer and less expensive. The growing availability of quick and safe procedures such as laparoscopy during the 1970s and 1980s made it easier for women to choose sterilization, and the legacy of medical reticence, exemplified

4  

Because data from the 1988 and 1990 NSFG predate the introduction of both injectable and implantable hormonal contraceptives, they are supplemented in this chapter by data from the 1992 and 1994 Ortho Birth Control Studies. The Ortho Birth Control Studies are an annual survey by the Ortho Pharmaceutical Corporation of contraceptive attitudes and the contraceptive methods used. The value of this survey is somewhat limited, however. Random sampling is not used, and the surveys tend to underrepresent black women and households with annual incomes greater than $50,000. Nevertheless, they do provide some insight into contraceptive use in the 1990s.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

by the ''120 rule,"5 eased as well. The sterilization decision has come to be based more on client request and preference rather than provider opinion, and female sterilization has increasingly come to be seen as the most foolproof method of contraception by women who become tired or distrustful of other methods and who appreciate the control that sterilization provides. Women also may choose sterilization because the burden of contraception most often falls on them. In addition, obstetricians and gynecologists may be more likely to discuss female sterilization with women than internists (or other clinicians) are to discuss male sterilization with men.

Reversible Contraception

Women currently using reversible contraception—approximately 21 million in 1988—contribute slightly less than half of all unintended pregnancies (Group B). Their demographic attributes are shown in Table 4-3.

The dynamics of pregnancy occurring despite the use of contraception are unclear, and both method failure (i.e., the condom broke because of manufacturing problems) and user failure (i.e., the condom broke because it was used incorrectly) must be taken into account. It is often difficult, as a practical matter, to distinguish clearly between a genuine contraceptive failure and the failure of an individual or couple to use a method properly and consistently. Only with methods that require no specific action once they are established, such as a contraceptive implant, can these distinctions be made with certainty.

One of the most important and difficult problems faced in understanding how pregnancy can occur in the presence of contraception is that the primary data source for computed rates is interviews (and questionnaires) with women and men in which the respondents are asked about their patterns of contraceptive use at the time that an unintended pregnancy occurred. Most people being interviewed understand intuitively that to admit that no contraception at all was being used or that it was being used improperly, despite no desire to become pregnant at the time, is in some sense an embarrassing admission, however honest it might be. The socially desirable answer, of course, is to say that contraception was being used carefully and consistently, but that an unintended pregnancy occurred anyway. Because of this problem, estimates of genuine contraceptive failure (the method was used perfectly, but pregnancy occurred nonetheless) are probably inflated by some unknown, but real factor. This is not

5  

Clinicians used to refuse to sterilize women until the patient's age multiplied by the number of live births she had had equaled 120; for example, a physician might refuse to sterilize a 30-year-old woman who had had three live births (30 × 3 = 90), but might agree to do so if she had had four live births (30 × 4 = 120)—hence the "120 rule."

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

TABLE 4-3 Women Who Reported No Intent to Become Pregnant and Were Using Reversible Methods of Contraception (Group B), by Age, Marital Status, Poverty Level, and Race and Ethnicity, 1988a

Characteristics

Percentage

Age

 

15–19

13.6

20–24

24.5

25–29

25.3

30–34

18.8

35–39

11.2

40–44

6.6

Total

100.0

Marital Status

 

Never married

38.2

Married

52.3

Formerly Married

9.5

Total

100.0

Poverty Level

 

<150%

20.1

150–299%

23.2

>300%

56.6

Total

100.0

Race/ethnicity

 

White

75.8

Black

12.2

Hispanic

8.4

Other

3.6

Total

100.0

 

a  

The denominator for these percentages is women who reported using reversible contraception.

SOURCE: National Center for Health Statistics. Unpublished tables from the 1988 National Survey of Family Growth. Tables 1-1, 1-2, 1-4, and 1-6 for 1988.

to say that method failures never occur because they do. Rather it is to suggest that some unintended pregnancies ascribed to method failure may in fact be due to user failure and even to nonuse.

There is also no doubt that using many of the reversible contraceptive methods correctly and consistently can be very challenging. For example, Oakley (1994) has sketched the chain of events that using an oral contraceptive requires a woman to master: obtaining pills, taking them in the correct order,

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

taking each pill within the appropriate time window, abstaining from sex or using a backup method when necessary, obtaining refills on time, stopping one cycle and starting the next at the right time, interpreting problems correctly (neither over-reacting nor under-reacting), and taking effective action to resolve problems (see Chapter 5 for more discussion of the skills required for contraceptive use). The point is that many reversible methods are difficult to use perfectly all of the time, and therefore user failure should be seen as reflecting both the skills of the user as well as the inherent complexity of many available reversible methods themselves.

Recognizing these realities, researchers studying contraceptive failure rates often distinguish between typical use and perfect use, thus providing some context for separating mechanical failure from user foible. Perfect use reflects contraceptive use that is consistently performed according to the specified instructions; all pregnancies occurring in the presence of perfect use are classified as method failures. Typical use, on the other hand, reflects a combination of actual method failure and user failure—a more real-world, everyday measure. Rates of failure are substantially higher with typical use than with perfect use.

Not surprisingly, in typical use, coitus-dependent methods are significantly less effective than coitus-independent methods, especially those that are longer-acting. For example, the first-year contraceptive failure rate for condoms and diaphragms ranges from 12 to 20 percent (Hatcher et al., 1994), and the 6-month failure rate of the female condom is estimated to be 12 percent (Trussell et al., 1994). By contrast, contraceptive implants and injections have less than a 1 percent failure rate (Ross, 1989; Hatcher et al., 1994). Overall, those reversible methods that are nearly impervious to user shortcomings are most effective in day-to-day life.

Jones and Forrest (1992) computed failure rates of several commonly used methods based on the 1982 and 1988 NSFG. These rates, shown in Table 4-4, were calculated on the basis of the first 12 months of use, and therefore may not reflect failure rates over longer periods of time. The investigators suggest that rates of contraceptive failure may have increased during the 1980s, especially for some methods. Failure rates for oral contraceptives, for example, increased from 6 to 8 percent between 1982 and 1988—a trend that is particularly worrisome given the fact that under conditions of perfect use, oral contraceptives yield only about one pregnancy in 1,000 women in the first year of use. This increase can also be seen in less reliable methods; for example, the failure rate for periodic abstinence increased from 16 to 25 percent during the 1980s.

It is important to emphasize that, given the imperfect array of contraceptives available to both men and women and the years of exposure to the risk of unintended pregnancy, some appreciable number of unintended pregnancies will inevitably occur over the life course. One simple computation suggests that this accumulates to a large risk over time. Ross (1989) offers the example of a young

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

TABLE 4-4 Percentages of Women Experiencing Contraceptive Failure During the First 12 Months of Use, Corrected for Underreporting of Abortion, by Method, 1982 and 1988 NSFGa

 

Percentage

 

Method

1982

1988

Oral contraceptive

6.2

8.3

Condom

14.2

14.8

Diaphragm

15.6

15.9

Periodic abstinence

16.2

25.6

Spermicides

26.3

25.2

Other

22.2

27.8

a  

Correction for underreporting of abortion is based on 1987 data from The Alan Guttmacher Institute and the Centers for Disease Control.

SOURCE: Jones EF, Forrest JD. Contraceptive failure rates based on the 1988 NSFG. Fam Plann Perspect. 1992;24:12–19:Table 1.

couple of undiminished fertility who use a contraceptive that is 95 percent effective. In this example, the couple experiences a monthly risk of pregnancy of about 1 percent. Over 10 years, that risk accumulates to a 70 percent probability that an unintended pregnancy will occur at some point during the decade. Similarly, Trussell and Vaughn (1989) have estimated that the average woman will experience one contraceptive failure for every 2.25 live births, a number that increases substantially if women who are in relationships in which at least one partner has been sterilized are excluded from the analysis (see also Harlap et al., 1991). These data underscore the fact that an appreciable part of both a woman's and a man's reproductive life span is spent at risk of unintended pregnancy, using a variety of reversible contraceptive methods that are rarely, if ever, 100 percent effective. In fact, Forrest (1993) has estimated that about 75 percent of a woman's reproductive years are spent trying to avoid pregnancy.

Contraceptive misuse and failure are not evenly distributed across all ages and stages of the reproductive life span. They are higher among unmarried women (and formerly married women in particular) and those whose incomes are 200 percent or less of the poverty level (Forrest, 1994a). The concentration of these contraceptive failures in certain groups of women is undoubtedly part of the underlying explanation for the concentration of unintended pregnancy in these same groups, as noted in Chapter 2.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Current Choices Among Reversible Methods

Women and their partners have a broad array of reversible contraceptive methods from which to choose, and the popularity of various methods has changed over time. Table 4-5 presents information about the results of these choices in 1988, showing the use of both contraceptive sterilization and reversible contraception (i.e., the women in Groups A and B in Figure 4-1). Table 4-6 supplements Table 4-5 by displaying contraceptive choices within the group of reversible methods only over the 1982–1990 interval.

Three issues stand out in reviewing Table 4-5. First, coitus-independent methods are the most popular among the women surveyed. Oral contraceptives were the most frequently used method in 1988; this was followed closely by female sterilization. Other methods, ranked in order of popularity, were condoms, male sterilization, the diaphragm, periodic abstinence, withdrawal, the IUD, and foam. Second, the rank order changes somewhat with the age of the user. For example, oral contraceptives were the most frequently used method among those 15–29 years old, but female sterilization was the most frequently used method among those 30–44 years old. Third, condom use was dramatically higher among adolescents than among older women. Data from the 1990 NSFG suggest a change in the rank order: female sterilization was the most frequently used method; this was followed by oral contraceptives. Data from the 1988 and 1990 NSFG do not reflect the current increase in the use of hormonal implants and injections; however, data from the 1994 Ortho Birth Control Study indicate the growing popularity of these methods (Peterson, 1995; Ortho Pharmaceutical Company, 1994).

It is probable that condom use is higher than is indicated by these data. The 1988 NSFG reported the more effective method when condoms were stated as being used with sterilization, oral contraceptives, IUDs, or diaphragms, thereby partially obscuring the importance of condoms. Concomitant use of condoms and any method other than these four was coded as condom use. When the data are retabulated to include all methods used, the number of women using condoms rises to 5.8 million, or approximately 17 percent of all users in 1988 (Mosher and Pratt, 1990). In addition, occasional use of condoms is not reported in the NSFG. Women are asked to report all methods they have used for 1 month or more, and thus may fail to report episodic condom use. A separate question about condom use suggests that 14 percent of women who reported condom use in response to this question did not report condoms as their current method (either alone or with another method), and this was especially true among younger women (Hatcher et al., 1994).

Because women at either end of the reproductive age span have relatively high rates of unintended pregnancy, it is useful to discuss their contraceptive use in more detail. Roughly, these two groups are women under age 20 and women age 40 and over.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

TABLE 4-5 Choice of Contraceptive Methods Among Women Who Use Either Contraceptive Sterilization or Reversible Contraception by Age, Marital Status, Poverty Level, Race and Education, and Religion, 1988a (in percent)

 

Sterilization

 

 

 

 

 

 

 

Characteristics

All

Methods

Female

Male

Oral

Contraceptive      

Condom

Diaphragm

IUD

Otherb

Total

100

28

12

31

15

6

2

6

Age

 

 

 

 

 

 

 

 

15–19

100

2

0

59

33

1

0

5

20–24

100

5

2

68

15

4

0

6

25–29

100

17

6

45

16

6

1

9

30–34

100

33

14

22

12

9

3

7

35–39

100

45

20

5

12

8

3

7

40–44

100

51

22

3

11

4

4

5

Marital Status

 

 

 

 

 

 

 

 

Never married

100

6

2

59

20

5

1

7

Married

100

31

17

21

14

6

2

9

Formerly married

100

51

4

25

6

5

4

5

Poverty Level

 

 

 

 

 

 

 

 

< 150%

100

37

4

36

13

2

3

5

150–299%

100

32

12

29

14

5

2

6

> 300%

100

22

14

30

16

8

2

8

Race/ethnicity

 

 

 

 

 

 

 

 

White

100

26

14

30

15

7

2

6

Black

100

38

1

38

10

2

3

8

Hispanic

100

32

4

33

14

2

5

10

Education

 

 

 

 

 

 

 

 

11 years

100

52

7

23

6

1

4

7

12 years

100

34

15

29

11

3

2

6

> 13 years

100

21

13

29

16

10

2

9

Religion

 

 

 

 

 

 

 

 

Protestant

100

32

12

29

13

4

NA

10

Catholic

100

22

12

33

16

6

NA

11

Jewish

100

12

13

15

22

27

NA

10

None

100

18

11

37

18

10

NA

6

a  

The denominator for these percentages is all women who use contraceptives in each category; for example, among women ages 15–19 who reported using some type of contraception, 59 percent used oral contraceptives.

b  

"Other" contraceptive methods include periodic abstinence, foam, withdrawal, douche, sponge, jelly or cream alone, and other methods.

SOURCES: Goldsheider C, Mosher WD. Patterns of contraceptive use in the United States: The importance of religious factors. Stud Fam Plann. 1991;22:102-115; Table 3; Mosher WD. Contraceptive practice in the US, 1982–1988. Fam Plann Perspect. 1990;22:198–205: Table 4.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Complete Table on previous page.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

TABLE 4-6 Trends in Choice of Reversible Contraceptive Methods Among Women, by Age, Marital Status, Poverty Level, and Race and Ethnicity, 1982 through 1990a

 

1982

 

 

 

 

1988

 

 

 

1990

 

 

 

 

Characteristics

Oral Contra- ceptive

Con- dom

Dia- phragm

IUD

Otherb

Oral Contra- ceptive

Con- dom

Dia- phragm

IUD

Other

Oral Contra- ceptive

Con- dom

Dia- phragm

IUD

Other

Total

42.5

18.2

12.3

10.8

16.2

50.6

24.1

9.4

3.3

12.6

49.2

30.6

4.8

2.4

13.0

Age

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15–19

64.2

20.9

6.0

1.3

7.6

59.8

33.4

1.0

0.0

5.8

52.0

44.0

0.0

0.0

4.0

20–24

60.0

11.6

11.1

4.6

12.8

72.9

15.5

4.0

0.3

7.3

61.4

28.0

0.7

1.1

8.8

25–29

43.2

13.4

14.5

12.9

15.0

57.8

20.3

7.1

1.7

13.1

61.0

24.5

3.0

0.5

11.0

30–34

29.6

22.3

14.7

16.5

16.9

40.2

22.4

16.6

5.4

15.4

44.0

29.3

8.6

1.7

16.4

35–39

14.2

28.9

9.7

18.7

28.6

14.7

33.3

21.8

7.6

22.6

29.4

28.6

9.2

2.8

30.0

40–44

3.7

34.1

12.7

18.9

30.7

12.0

39.3

14.6

13.9

20.2

10.2

42.8

17.7

8.4

20.9

Marital status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Never Married

56.1

12.3

14.2

5.7

11.7

64.3

21.4

5.3

1.4

7.6

56.6

33.7

0.9

0.7

8.1

Married

33.5

24.5

11.3

1.7

18.8

39.8

27.9

12.1

3.9

16.3

43.6

29.6

8.7

3.0

15.1

Formerly married

49.6

16.1

11.7

20.1

16.1

55.4

12.9

11.6

7.9

12.2

49.7

21.5

2.0

5.5

21.3

Poverty level

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

< 150%

52.4

13.0

8.8

11.9

13.9

60.2

19.6

4.4

6.4

9.4

53.2

32.0

1.3

2.4

11.1

150–299%

39.5

18.1

11.1

10.3

21.0

50.8

21.8

9.5

4.6

13.3

53.5

30.0

2.0

5.0

9.5

> 300%

39.3

20.9

15.0

10.6

14.1

45.3

23.6

13.0

2.8

15.3

46.7

28.7

7.2

1.7

15.7

Race/ethnicity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

White

40.6

20.1

14.1

8.9

16.3

49.1

25.3

11.0

2.5

12.1

49.8

29.7

5.2

2.3

13.0

Black

55.2

9.2

4.7

13.6

17.2

62.2

16.5

3.3

5.2

12.8

49.4

33.6

2.8

2.4

11.8

Hispanic

41.7

9.5

6.5

26.5

15.7

52.2

21.3

3.8

7.8

14.9

51.9

28.3

2.5

3.1

14.2

a  

In each category, the denominator is women using reversible contraceptives. For example, 64.2 percent of 15–19-year-old women who reported using reversible contraception in 1982 used oral contraceptives, 59.8 percent used oral contraceptives in 1988, and 52.0 percent used oral contraceptives in 1990.

b  

"Other" contraceptives include periodic abstinence, foam, withdrawal, douche, sponge, jelly or cream alone, and other methods.

SOURCES: National Center for Health Statistics. Unpublished tables from the 1982 and 1988 National Survey of Family Growth. Tables 1-7, 1-8, 1-10, 1-12, for 1982. Peterson L. Contraceptive use in the United States: 1982–1990. Advance Data. National Center for Health Statistics. 1995(260):1–15. Tables 4 and 5.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Complete Table on previous page.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Adolescents Nearly 80 percent of sexually active teenage women (i.e., those who have had intercourse within the last 3 months) reported using some type of contraception in 1988, and as noted above, they most frequently used oral contraceptives and condoms (Forrest, 1994a). To get a more refined picture of this group, it is helpful to separate the broad category of adolescents into early (12–14), middle (15–17), and late (18–19) adolescence, because contraceptive use varies dramatically across these age groups. Very little is known about the contraceptive use of early adolescents because girls under age 15 are often excluded from surveys on sexual activity, and moreover, a substantial portion of sexual activity among this group is unanticipated or non-voluntary, which makes the use of any method unlikely (see Chapter 7) (Moore et al., 1989).

More information is available about contraceptive use by older teens. In 1988, most sexually active 15–17-year-olds who used contraception reported using oral contraceptives (53 percent); this was followed by the use of condoms (40 percent). The rank order of popularity of these contraceptives apparently switched by 1990, when condoms became the most popular contraceptive among 15–17-year-olds (52 percent); this was followed by oral contraceptives (41 percent). Oral contraceptives have consistently been the most popular choice among 18–19-year-olds, with condoms a distant second (Peterson, 1995).

Women 40 and Over With regard to women at the other end of the reproductive life span, 92 percent of sexually active women aged 40–44 reported using some method of contraception in 1988, with a heavy reliance on contraceptive sterilization (primarily female sterilization) (Forrest, 1994a). Nonetheless, unintended pregnancy is quite common among those women who use reversible methods, primarily because the nonsurgical methods that they choose are the least effective: for example, only 12 percent of women who use reversible methods choose oral contraceptives. The most popular method after sterilization is the condom (39 percent), which has an appreciable failure rate, as noted earlier (Table 4-4).

Although in the past women in this age group were considered to be at greater risk than younger women of adverse side effects from oral contraceptives, that is no longer the case for most women (Kaeser, 1989). Data from the 1994 Ortho Birth Control Study suggest that use of oral contraceptives among women is this age category may have risen very slightly in the early 1990s (Ortho Pharmaceutical Company, 1994).

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Reversible Contraceptive Methods: Types and Trends

In general, methods that are both long-acting6 and coitus-independent (such as contraceptive implants) have the highest effectiveness rates but are used by relatively few women; less than 10 percent of all women who report using reversible methods of contraception use methods that are both long-acting and coitus-independent. Methods that are coitus-independent but require complicated compliance regimens (that is, oral contraceptives) are often less effective in typical use than those that are long-acting; nonetheless, oral contraceptives in particular remain the most popular method of reversible contraception. Although methods that are coitus-dependent are generally the least effective in preventing pregnancy, they are important to highlight because they are so popular among women at especially high risk of unintended pregnancy (such as younger women, unmarried women, and older women who are not relying on their own or their partner's sterilization to avoid pregnancy) and because they are often one part of a dual method system, as discussed later in this chapter. Table 4-6 presents data on contraceptive choices over the 1982–1990 interval within the group of reversible methods only.

Long-Acting Coitus-Independent Methods There are three broad classes of contraceptive methods that are both long-acting and coitus-independent: implantable hormones, injectable hormones, and IUDs. Given their high rates of effectiveness, they are very important in preventing unintended pregnancy. Few survey data are available to describe the patterns of use of contraceptive implants and injectables because they are such recent arrivals in the United States. Norplant, a contraceptive implant that releases the synthetic progestin levonorgestrel through capsules that are placed in the upper arm, provides highly effective contraceptive protection for up to 5 years; it was approved for use in the United States in 1990. Four percent of reproductive-age women who report using reversible contraception currently use this method (Ortho Pharmaceutical Company, 1994), and about half of the Norplant users are unmarried (The Alan Guttmacher Institute, 1993). The issue of implant removal has gained added visibility recently, as exemplified by a class action liability lawsuit based on alleged removal problems. (Additional material on Norplant is in Chapters 5 and 7.)

Depo-Provera is an injectable progestin, recently approved for use in the United States, that provides contraceptive protection for at least three months (Hatcher et al., 1994). In 1994, approximately 3 percent of reproductive-age

6  

Long-acting means that the method itself is effective for an extended period of time, as is the case, for example, with contraceptive implants (5 years of effectiveness) or the CuT 380A (Paraguard) IUD (8 years of effectiveness). These methods have the added advantage that the individual user need take only minimal action to maintain the method once it is in place.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

women who reported the use of a reversible method relied on Depo-Provera (Ortho Pharmaceutical Company, 1994). Although the injectable contraceptive was licensed for sale in the United States later than contraceptive implants, it is rapidly increasing its market share, and informal reports from clinic directors confirm that current demand for Depo-Provera is high (R. Wisman, pers. com., 1994).

Even though the IUD is long-acting and coitus-independent, use of this method decreased in all age groups during the 1980s. This decrease has been attributed to the withdrawal of the IUD from the U.S. market by two major manufacturers in 1985 and 1986 because of various concerns about liability exposure (Forrest, 1986). By 1988, only 700,000 women were using this method (3.3 percent of those women using reversible contraception), and by 1990, this level had dropped to 2.4 percent (Table 4-6) (Mosher, 1990; Peterson, 1995). Although IUDs are currently available in the United States, the association with a litigious past and the paucity of clinicians with experience in inserting IUDs continues to hamper a renewal of their widespread use.

Other Coitus-Independent Methods Although their popularity has waned slightly since the 1960s, oral contraceptives were the leading method of reversible contraception during the 1980s, especially among never-married women and women under 30 years old. Oral contraceptive use decreased in the 1970s, but rose again in the 1980s (Mosher and Pratt, 1990). The increase in oral contraceptive use during the 1980s was primarily due to uptake among women in their 20s; use among adolescent women reporting contraceptive use declined during this period (from 64.2 to 59.9 percent). Between 1988 and 1990, oral contraceptive use appeared to decrease among women in their early 20s, but increase among women in their late 20s. Oral contraceptive use among women aged 35–39 who reported using reversible contraceptives also rose in 1990, from 14.7 to 29.4 percent. Oral contraceptive use was higher among low-income women than more affluent women early in the 1980s, but by 1990, economic status did not appear to affect the likelihood of oral contraceptive use among women using reversible contraception.

Coitus-Dependent Methods During the 1980s, reliance on condoms increased both overall and among certain subpopulations, but most notably among adolescent women, never-married women, and minority women. Condom use increased significantly among 15–19-year-olds who reported using reversible contraception, from 20.9 to 33.4 percent between 1982 and 1988 and to 44.0 percent in 1990. Among 20–24-year-olds who reported using reversible contraception, condom use rose from 11.6 to 15.5 to 28.0 percent, respectively. Condom use did not change among married couples using reversible contraception, but it did increase significantly among never-married and formerly married

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

women. For example, condoms were the second leading method of choice among never-married women who reported using reversible contraception in 1988 and 1990, increasing from 12.3 percent in 1982 to 21.4 percent in 1988 and to 33.7 percent in 1990.

The popularity of other coitus-dependent methods, such as the diaphragm, cervical cap, contraceptive sponge, spermicides, periodic abstinence, and withdrawal, declined in the 1980s (Mosher, 1990). The decline was not uniform, however. For example, the decline in diaphragm use among women who reported use of reversible contraception was most apparent among younger women. In 1982, 6.0 percent of 15–19-year-olds, 11.1 percent of 20–24-year-olds, and 14.5 percent of 25–29-year-olds reported using diaphragms; by 1990, those proportions had decreased to 0.0, 0.7, and 3.0, respectively.

Risks and Benefits of Reversible Contraceptive Methods Reversible methods vary in their abilities to prevent unintended pregnancy, as noted in Table 4-4, and each is also associated with different risks and side effects. In addition, each has significant noncontraceptive benefits that are discussed much less frequently in the popular literature. This material is presented in Table 4-7.

Contraceptive Use Among Men

Much of the information about contraception, as noted earlier, is based on reports from women. Although women are often asked what methods their male partners use, it is important to review data derived from men themselves, because men have consistently contributed to their partners' protection against unintended pregnancy through their own use of contraceptive methods. This section discusses men's use of contraception at various stages of their reproductive lives, reflecting in particular the increase in men's use of condoms in the 1980s.

Use of Male Methods of Contraception at First Intercourse

Data from the National Survey of Adolescent Men suggest that condom use accounts for more than half of the contraception that occurs at first intercourse (Pleck et al., 1993). Among teenage men in 1988, for example, 55 percent used condoms and 38 percent used less effective methods such as withdrawal or no method; only 7 percent used an effective female method such as oral contraceptives. Condom use at first intercourse rose dramatically in this age group during the 1980s, and at the same time, use of ineffective methods or no contraception at first intercourse fell from 71 to 38 percent between 1979 and 1988 (Pleck et

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

TABLE 4-7 Noncontraceptive Benefits, Risks, and Side Effects of Various Reversible Contraceptive Methods

Method

Noncontraceptive Benefits

Risks

Side Effects

Implantable contraceptives

Decreased risk of PID,a ovarian cancer, and endometrial cancers; lactation not disturbed; decreased menstrual blood loss and risk of anemia; decreased menstrual pain; suppression of pain associated with ovulation

Infection at implant site

Tenderness at implant site, menstrual cycle disturbance (amenorrhea becomes less common over time), weight gain, breast tenderness, headaches, ovarian enlargement, dizziness, nausea, acne, dermatitis, hair loss        

Injectable contraceptives

Decreased risk of PID, ovarian cancer, and endometrial cancers; decreased menstrual blood loss and risk of anemia; decreased menstrual pain; suppression of pain associated with ovulation; decreased frequency of seizures

Decreased bone density

Menstrual cycle disturbance (amenorrhea becomes more common over time), weight gain, breast tenderness, depression, delay in return of fertility, decreased HDL cholesterol levels, headaches        

IUDs

None known; however progestin-releasing IUDs may decrease menstrual blood loss and pain

PID, perforation of the uterus, anemia

Menstrual cramping, spotting, increased bleeding        

Oral contraceptives

Protects against acute infection of the fallopian tubes, PID, ovarian cancer, endometrial cancer, choriocarcinoma, benign breast masses, fibroids, ovarian cysts; decreased menstrual blood loss and risk of anemia; decreased menstrual pain; suppression of pain associated with ovulation              

Estrogen-associated: blood clot complications, stroke, liver tumors, hypertension, heart attacks, cervical erosion or ectopia  

Estrogen-associated: nausea, headaches, fluid retention, weight gain, increased breast size, breast tenderness, stimulation of breast tumors, watery vaginal discharge, rise in cholesterol concentration in gallbladder bile, uterine fibroids    

 

 

Progestin-associated: diabetes-related changes, hypertension, heart attacks

 

 

 

Possible risks: breast cancer, cervical cancer, liver cancer

Progestin-associated: weight gain, depression, fatigue, headaches, decreased libido, acne, increased breast size, breast tenderness, increased LDL cholesterol level, decreased HDL cholesterol level, chronic itch        

Male condoms

Protects against STDs,b including HIV-AIDS; delays premature ejaculation; erection enhancement; prevention of sperm allergy

None known

Decreased sensation during intercourse, allergy to latex, possible interference with erection

Female condoms

Protects against STDs, including HIV-AIDS

None known

Decreased sensation during intercourse, allergy to polyurethane

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Complete Table on previous page.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Method

Noncontraceptive Benefits

Risks

Side Effects

Barrier methods (diaphragm and cervical cap)

Protects against STDs, prevention against HIV-AIDS not proven; diaphragm protects against PID and cervical neoplasia

Vaginal trauma, toxic shock syndrome

Vaginal and urinary tract infection; vaginal discharges if not removed appropriately; allergy to spermicide, rubber, or latex; bladder or rectal pain, penile pain

Spermicides

Protects against STDs, prevention against HIV-AIDS not proven

None proven

Vaginal irritation, yeast vaginitis, allergy to spermicidal agents

a  

Pelvic inflammatory disease.

b  

Sexually transmitted diseases.

SOURCE: Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology, 16th revised ed. New York, NY: Irvington Publishers, Inc.; 1994.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

al., 1993). This increase may reflect deepening concern over HIV-AIDS transmission. Since 1988, there appears to have been no further growth overall in the use of condoms at first intercourse among men (Ku et al., 1993c; Pleck et al., 1993).

Withdrawal is also a method frequently used early in a man's reproductive life span, although it is being reported less often in recent years. It is useful to note that withdrawal, although not very effective, is still much more effective than failing to withdraw altogether, because the 1-year pregnancy rate of withdrawal is 19 percent and the 1-year pregnancy rate of no contraception at all is 85 percent (Hatcher et al., 1994).

Use of Male Methods by Married Men

Although the role of men in providing contraceptive protection at first intercourse is somewhat well known, less attention has been paid to the use of male contraceptive methods by married men. Since nationally representative data about the contraceptive practices of married women were first collected in 1973, male partners have been found to provide at least one-fourth of the contraception that is reported. As measured at three points in time (1973, 1988, and 1990), condom use among married men has remained stable at 14 percent. Sterilization, however, rose from 11 to 19 percent between 1973 and 1990 (Mosher, 1990; Peterson, 1995).

Although vasectomy is an important contraceptive method, few data are available in the literature to help provide an understanding of the dynamics of its use. Miller and colleagues (1991) report that married couples who are less traditional and more egalitarian are more likely to choose male over female sterilization; in addition, when the wife feels that communication between the spouses is effective, vasectomy is again more likely to be chosen over female sterilization. As shown in Table 4-5, there are also racial and ethnic differences in the reliance of women on male versus female sterilization. For example, very few minority women report that they rely on their partner's sterilization to protect them against unintended pregnancy. As noted earlier, vasectomy is a highly effective contraceptive method, but unfortunately, nearly 40 percent of men fail to return for a post-vasectomy semen analysis. If sperm are still present in the vas deferens of these men who lack follow-up care, they remain at risk of causing an unintended pregnancy for some time (J.M. Haws, pers. com., July 1994).

Age and Condom Use

Condom use has increased in the past decade, reaching especially high levels among adolescents. However, data from the 1991 Follow-up of the National

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Survey of Adolescent Males and the 1991 National Survey of Men suggest that condom use decreases as men grow older (see Figure 4-2) (Pleck et al., 1993). Although the measures are not completely comparable across the two data sets, there is clearly a negative association between condom use and age. Although older men are part of an earlier cohort who initiated sexual activity before the age of AIDS and safe sex, there are also indications that the decline in condom use reflects the maturation of relationships and the transition to female methods of contraception (including sterilization) that are often more effective in preventing pregnancy (Landry and Camelo, 1994).

Even among adolescents aged 15 to 19, there appears to be a decrease in condom use by age, reflecting movement to female methods after initial sexual experiences during which condoms are often used. One study reports that 16-year-old men who are sexually active use condoms more than 19-year-olds (Sonenstein et al., 1989). Figure 4-3 provides an example of this by showing the contraceptive method used at last intercourse for sexually active adolescent men in 1988 and for the same young men nearly 3 years later, in 1991.

Race, Ethnicity, and Condom Use

Condom use varies by racial and ethnic affiliation. Black men are the most likely to report using condoms at all ages. Among adolescents, black men use condoms at higher rates than either Hispanic men or non-Hispanic white men (Pleck et al., 1991). The average percentage of times condoms were used increased among adolescent men of all ages between 1988 and 1991, but particularly among Hispanics (nearly 6 percent increase) and whites (nearly 5 percent increase) (Centers for Disease Control and Prevention, 1993). Nationally representative data about condom use among adult Hispanic men are not available.

Although condom use among black adolescent men is higher at last intercourse than among white men of comparable age, condom use at first intercourse is lower. Since black men, on average, initiate sex about 1 year earlier than white men, and since earlier ages of first intercourse are associated with less use of contraception, some of the racial difference in condom use at first intercourse is attributable to differentials in age at initiation (Sonenstein et al., 1989). However, after age at initiation is controlled along with other confounding variables, being a young black man continues to be associated with lower condom use at first intercourse (Ku et al., 1993a).

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Figure 4-2

Condom use among men, by age, 1991. Source: Pleck JH, Sonenstein FL, Ku L. Changes in adolescent males' use of and attitudes toward condoms, 1988–1991. Fam Plann Perspect. 1993:25:106–110, 117.

Socioeconomic Status and Condom Use

Among adolescents, significant associations have been found in one study between socioeconomic measures and the use of effective contraception. However, the direction of the association was unanticipated by the researchers. Adolescent men with lower socioeconomic status were expected to report lower rates of effective contraceptive use, yet it was found that, net of other variables, use of effective contraception was higher among sexually experienced men living in neighborhoods with high poverty rates and lower among more affluent men (Ku et al., 1993b; Sonenstein et al., 1992). Multivariate analyses have not uncovered any systematic associations between the socioeconomic status of adolescent men and their use of condoms. Measures of family income, parental education, and welfare receipt are not significantly related to recent condom use among sexually experienced men (Pleck et al., 1991; Ku et al., 1992). By contrast, adult men with more education report greater condom use than those with less education (Tanfer et al., 1993).

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Figure 4-3

Form of contraception used at last intercourse as teen males grow older. Source: Pleck JH, Sonenstein FL, Ku L. Changes in adolescent males' use of and attitudes toward condoms, 1988–1991. Fam Plann Perspect. 1993:25:106–110, 117.

Use of Dual Contraceptive Methods

Given the appreciable failure rates of single reversible methods, it is important to consider the use of two methods simultaneously to prevent unintended pregnancy. Dual methods often involve the active participation of both male and female partners (particularly if one of the two methods chosen is a condom), and use of dual methods can expand the role of men in preventing unintended pregnancy.

Depending on the combination of methods selected, the use of two methods simultaneously can also reduce the risk of STDs. For example, the use of two female methods, such as oral contraceptives and foam, provides more complete

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

protection against unintended pregnancy than the use of either method alone. The use of both a female method and a condom, however, not only provides added protection against unintended pregnancy but is also a more effective way for women and men to protect themselves from the risk of contracting an STD.

There is some evidence that the use of dual methods is increasing. For example, in 1979 a mere 3 percent of sexually active urban men aged 17–19 reported using both a condom and a female method of contraception simultaneously; this rate rose to 16 percent by 1988 (Zelnick and Kantner, 1980; Pleck et al., 1993). More recently, 25 percent of all women in the 1992 Ortho Birth Control Study reported using condoms concurrently with another method, and more than half of the women using less effective methods such as periodic abstinence reported using condoms as well (Forrest and Fordyce, 1993). Dual usage appears to have increased between 1992 and 1994; 46 percent of the women surveyed in the 1994 Ortho Birth Control Study reported using condoms in addition to their primary contraceptive. Among this group of dual-method users, nearly half claim that they are doing so solely for the prevention of unintended pregnancy (Ortho Pharmaceutical Company, 1994).

Sexually Transmitted Diseases

As just noted, sexual activity can result not only in unintended pregnancies but also in the transmission of STDs. However, there are other links between unintended pregnancy and STDs as well: many risk factors for STDs and unintended pregnancy are the same; unintended pregnancy precludes the opportunity to resolve an STD before conception; and the desire to achieve protection against both STDs and unintended pregnancy may influence the choice of contraceptive methods, including dual methods.

STDs are spread by the transfer of infectious organisms from one person to another during sexual contact. Although it is difficult to calculate the prevalence of STDs, there are currently an estimated 56 million cases of viral STDs in the United States, and approximately 12 million new cases of both viral and nonviral STDs occur annually (Centers for Disease Control and Prevention, 1993). Two-thirds of new cases occur to people under 25 years of age, a cohort that also contributes heavily to unintended pregnancy, and approximately 3 million adolescents acquire an STD every year (Donovan, 1993). More than 20 organisms and syndromes are now recognized as STDs, including curable nonviral infections (e.g., chlamydia, gonorrhea, syphilis, or chancroid) and viral infections that are not curable, but are treatable (e.g., human papillomavirus or genital herpes) or preventable (e.g., hepatitis B virus through the hepatitis B vaccine) (Centers for Disease Control and Prevention, 1993; Alan Guttmacher Institute, 1994). Many of these STDs, if left untreated, can result in serious health repercussions not only for the man or woman who is infected, but also for a developing fetus.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Of great concern at present is HIV, a relatively new viral STD. HIV infection results in AIDS. AIDS is currently both incurable and fatal, although antiretroviral therapies are available for treatment. Nearly 1 million people in the United States were estimated to be infected with HIV in 1993—approximately 1 in 100 men and 1 in 800 women (Centers for Disease Control and Prevention, 1993). Perinatal transmission of HIV occurs in approximately 20 to 30 percent of births to infected mothers (Hatcher et al., 1994). Nearly 80 percent of AIDS cases are to people between the ages of 20 and 44, the prime childbearing years (Centers for Disease Control and Prevention, 1993).

The risk factors for STD infection overlap those for unintended pregnancy. For example, the risk of both unintended pregnancy and STD infection is greater for women and men who initiate sexual intercourse at lower ages, for those who have a greater number of both current and lifetime sexual partners, and for those who have a higher frequency of intercourse (Centers for Disease Control and Prevention, 1993; see also Kost and Forrest, 1992).

One particularly unfortunate consequence of unintended pregnancy is that it often precludes the chance to resolve an STD before conception or to consider avoiding pregnancy altogether because of the presence of an incurable STD that poses serious risks to a fetus, such as HIV-AIDS (Chapter 3 includes additional discussion of other opportunities for health promotion that are missed because a pregnancy is unintended). STDs left untreated in pregnant women can result in premature delivery, infection in the newborn, or infant death (Centers for Disease Control and Prevention, 1993).

Finally, because sexual activity often carries a risk of both unintended pregnancy and STD transmission, the choice of contraceptive methods has become more complicated. As suggested in the previous section on dual-method use, it is often necessary to use more than one method to prevent both STDs and unintended pregnancy. But individuals and couples may attach differing priorities to these two goals, and their priorities may change over time and across relationships. Moreover, couples may find it difficult to use two methods simultaneously. In this era of AIDS and the increasing incidence of other STDs, research on the determinants of contraceptive behavior has yet to take into consideration this complicated calculus. Two notable exceptions are the research by Kost and Forrest (1992), in which contraceptive decision-making was examined from the perspective of preventing both pregnancy and STDs, and the research by Landry and Camelo (1994), who reported on discussions with young, unmarried people about their use of contraception in both preventing pregnancy and avoiding STDs.

In this context, it is important to note that although condoms are the most effective contraceptive method for reducing STD transmission, other methods can also provide some protection against selected pathogens (Table 4-8). Unfortunately, no single method at present provides maximum protection against both unintended pregnancy and all STDs.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

TABLE 4-8 Effects of Contraceptives on Bacterial and Viral STDs

Contraceptive Methods

Bacterial STD

Viral STD      

Condoms

Protective

Protective      

Spermicides with nonoxynol-9

Protective against gonorrhea and chlamydia

Undetermined in vivo      

Diaphragms

Protective against cervical infection; associated with vaginal anaerobic overgrowth

Protective against cervical infection      

Oral contraceptives

Associated with increased cervical chlamydia; protective against symptomatic pelvic inflammatory disease

Not protective      

IUDs

Associated with pelvic inflammatory disease in first month after insertion

Not protective      

Rhythm method

Not protective

Not protective

 

SOURCES: Ehrhardt AA, Wasserheit JN. Age, gender, and sexual risk behaviors for sexually transmitted diseases in the United States. In Research Issues in Human Behavior and Sexually Transmitted Diseases in the AIDS Era. Wasserheit JN, Aral SO, Holmes KK, Hitchcock PJ, eds. Washington, DC: American Society for Microbiology; 1991. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology, 16th revised ed. New York, NY: Irvington Publishers, Inc.; 1994: Table 4-2.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Conclusion

Several interesting conclusions emerge from an exploration of the patterns of contraceptive use as they relate to unintended pregnancy. First, women who report using reversible means of contraception (a large group) and women who report using no contraception at all despite having no clear intent to become pregnant (a small group) contribute roughly equally to the pool of unintended pregnancies. That is, about half of all unintended pregnancies derive from women who are not actively seeking pregnancy and who are using reversible contraception; the other half derive from women who are also not actively seeking pregnancy but who nonetheless are not using contraception. Many women and couples who are not intending to become pregnant move between these two groups, sometimes practicing contraception and sometimes not.

Contraceptive use has increased in recent years, primarily because of a rise in contraceptive female sterilization; moreover, the participation of men in providing reversible contraceptive protection is increasingly important, particularly at first intercourse. Nonetheless, unintended pregnancy continues to occur among couples who use reversible methods of contraception because many reversible methods are of only limited effectiveness even under conditions of perfect use, and because of the misuse of these same methods, some of which can be explained by the difficult compliance regimens that many require. Overall, coitus-dependent methods are much more susceptible to user failure than are long-acting coitus-independent methods, and thus couples relying on coitus-dependent methods are at greater risk of unintended pregnancy.

To reduce the risk of unintended pregnancy to the bare minimum, short of sterilization, couples are increasingly using two methods at once. Depending on which two methods are selected, dual-method use can help to reduce the risk of both STD transmission and unintended pregnancy. Indeed, the whole process of method selection has been complicated by the increasing presence of STDs and the importance of sexually active couples protecting themselves against both threats.

References

The Alan Guttmacher Institute. Sex and America's Teenagers. New York, NY; 1994.

The Alan Guttmacher Institute. Norplant: Opportunities and Perils for Low-Income Women. Special Report No. 2. New York, NY; 1993.


Centers for Disease Control and Prevention. Division of STD/HIV Prevention Annual Report. Atlanta, GA; 1993.


Donovan P. Testing Positive: Sexually Transmitted Disease and the Public Health Response. New York, NY: The Alan Guttmacher Institute; 1993.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Ehrhardt AA, Wasserheit JN. Age, gender, and sexual risk behaviors for sexually transmitted diseases in the United States. In Research Issues in Human Behavior and Sexually Transmitted Diseases in the AIDS Era. Wasserheit JN, Aral SO, Holmes KK, Hitchcock PJ, eds. Washington, DC: American Society for Microbiology; 1991.


Forrest JD. Contraceptive use in the United States: Past, present and future. Adv Popul. 1994a;2:29–48.

Forrest JD. Epidemiology of unintended pregnancy and contraceptive use. Am J Obstet Gynecol. 1994b;170(5):1485–1489.

Forrest JD. Timing of reproductive stages. Am J Obstet Gynecol. 1993;82:110.

Forrest JD. The end of IUD marketing in the United States: What does it mean for American women? Fam Plann Perspect. 1986;18:52–56.

Forrest JD, Fordyce RR. Women's contraceptive attitudes and use in 1992. Fam Plann Perspect. 1993;23:175–179.

Forrest JD, Singh S. The sexual and reproductive behavior of American women, 1982–1988. Fam Plann Perspect. 1990;22:206–214.


Goldsheider C, Mosher WD. Patterns of contraceptive use in the United States: The importance of religious factors. Stud Fam Plann. 1991;22:102–115.

Grady WR, Haywood MD, Florcy FA. Contraceptive discontinuation among married women in the United States. Stud Fam Plann. 1988;19:227–235.


Harlap S, Kost K, Forrest JD. Preventing Pregnancy, Protecting Health: A New Look at Birth Control Choices in the United States. New York, NY: The Alan Guttmacher Institute; 1991.

Hatcher RA, Trussell J, Stewart F, Stewart GK, Kowal D, Guest F, Cates W, Policar MS. Contraceptive Technology, 16th revised ed. New York, NY: Irvington Publishers, Inc.; 1994.

Henshaw SK, Silverman J. The characteristics and prior contraceptive use of US abortion patients. Fam Plann Perspect. 1988;20:158–168.


Jones EF, et al. Unintended pregnancy, contraceptive practice and family planning services in developed countries. Fam Plann Perspect. 1988;20:53–67.

Jones EF, Forrest JD. Contraceptive failure rates based on the 1988 NSFG. Fam Plann Perspect. 1992;24:12–19.


Kaeser L. Reconsidering the age limits of pill use. Fam Plann Perspect. 1989;21:273–274.

Kost K, Forrest JF. American women's sexual behavior and exposure to risk of sexually transmitted diseases. Fam Plann Perspect. 1992;24:244–254.

Ku L, Sonenstein FL, Pleck JH. The dynamics of condom use among young men during and between sexual relationships. In press.

Ku L, Sonenstein F, Pleck J. Factors influencing first intercourse for teenage men. Public Health Rep. 1993a;108:680–694.

Ku L, Sonenstein FL, Pleck JH. Neighborhood, family and work: Influence on the premarital behaviors of adolescent males. Soc Forces. 1993b;72:479–503.

Ku L, Sonenstein FL, Pleck JH. Young men's risk behaviors for HIV infection and sexually transmitted diseases, 1988 through 1991. Am J Public Health. 1993c;83:1609–1615.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Ku L, Sonenstein F, Pleck JH. The association of AIDS education and sex education with sexual behavior and condom use among teenage men. Fam Plann Perspect. 1992;24:100–106.

Landry DJ, Camelo TM. Young unmarried men and women discuss men's role in contraceptive practice. Fam Plann Perspect. 1994;26:222–227.

Laumann EO, Gagnon JH, Michael RT, Michaels S. The Social Organization of Sexuality: Sexual Practices in the United States. Chicago, IL: University of Chicago Press; 1994.


Miller WB, Shain RN, Pasta DJ. Tubal sterilization of vasectomy: How do married couples make the choice? Fertil Steril. 1991;56:278–284.

Moore KA, Nord CW, Peterson JL. Non-voluntary sexual activity among adolescents. Fam Plann Perspect. 1989;21:110–114.

Mosher WD. Contraceptive practice in the US, 1982–1988. Fam Plann Perspect. 1990;22:198–205.

Mosher WD, Bachrach CA. Contraceptive use, United States, 1980. Vital and Health Statistics, Series 23, No. 12. DHHS Pub. No. (PHS) 86-1988. Washington, DC: U.S. Government Printing Office; September 1986.

Mosher WD, McNally JW. Contraceptive use at first premarital intercourse: United States, 1965–1988. Fam Plann Perspect. 1991;23:108–116.

Mosher WD, Pratt WF. Contraceptive use in the United States, 1973–88. Advance Data from Vital and Health Statistics; No. 182. Hyattsville, MD: National Center for Health Statistics; 1990.


National Center for Health Statistics. Unpublished tables from the 1982 and 1988 National Survey of Family Growth.


Oakley D. Rethinking patient counselling techniques for changing contraceptive behavior. Am J Obstet Gynecol. 1994;170:1585–1590.

Ortho Pharmaceutical Company. Unpublished data from the 1994 Ortho Birth Control Study; 1994.


Peterson L. Contraceptive use in the United States: 1982–1990. Advance Data from Vital and Health Statistics; No. 260. Hyattsville, MD: National Center for Health Statistics; 1995.

Pleck JH, Sonenstein FL, Ku L. Changes in adolescent males' use of and attitudes toward condoms, 1988–1991. Fam Plann Perspect. 1993:25:106–110, 117.

Pleck JH, Sonenstein FL, Ku LC. Adolescent males' condom use: Relationships between perceived cost-benefits and consistency. J Marriage Fam. 1991;53:733–746.


Ross JA. Contraception: Short-term vs. long-term failure rates. Fam Plann Perspect. 1989;21:275–277.


Sonenstein FL, Pleck JH. The male role in family planning: What do we know? Paper prepared for the Committee on Unintended Pregnancy, Institute of Medicine. Washington, DC; 1994.

Sonenstein FL, Pleck JH, Ku LC. Sexual activity, condom use and AIDS awareness among adolescent males. Fam Plann Perspect. 1989;21:152–158.

Sonenstein FL, Pleck JH, Ku LC. Cost and Opportunity Factors Associated with Pregnancy Risk Among Adolescent Males. Paper presented at the Annual Meeting of the Population Association of America. Denver, CO; April 30, 1992.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Statistical Abstract of the United States, 1993. Table No. 109. Washington, DC: U.S. Department of Commerce; 1993.

Tanfer K, Grady WR, Klepinger DH, Billy JOG. Condom use among US men, 1991. Fam Plann Perspect. 1993;25:61–66.

Trussell J, Sturgen K, Strickler J, Dominik R. Comparative contraceptive efficacy of the female condom and other barrier methods. Fam Plann Perspect. 1994;26:66–72.

Trussell J, Vaughn B. Aggregate and lifetime contraceptive failure in the United States. Fam Plann Perspect. 1989;21:226.


Zelnik M, Kantner JF. Sexual and contraceptive experience of young unmarried women in the United States, 1976 and 1971. Fam Plann Perspect. 1977;9:55–61.

Zelnik M, Kantner JF. Sexual activity, contraceptive use and pregnancy among metropolitan-area teenagers: 1971–1979. Fam Plann Perspect. 1980;12:230–1, 233–237.

Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 91
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 92
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 93
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 94
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 95
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 96
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 97
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 98
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 99
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 100
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 101
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 102
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 103
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 104
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 105
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 106
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 107
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 108
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 109
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 110
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 111
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 112
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 113
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 114
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 115
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 116
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 117
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 118
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 119
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 120
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 121
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 122
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 123
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 124
Suggested Citation:"Patterns of Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×
Page 125
Next: Basic Requirements: Contraceptive Knowledge and Access »
The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families Get This Book
×
Buy Paperback | $100.00 Buy Ebook | $79.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

Experts estimate that nearly 60 percent of all U.S. pregnancies--and 81 percent of pregnancies among adolescents--are unintended. Yet the topic of preventing these unintended pregnancies has long been treated gingerly because of personal sensitivities and public controversies, especially the angry debate over abortion. Additionally, child welfare advocates long have overlooked the connection between pregnancy planning and the improved well-being of families and communities that results when children are wanted.

Now, current issues--health care and welfare reform, and the new international focus on population--are drawing attention to the consequences of unintended pregnancy. In this climate The Best Intentions offers a timely exploration of family planning issues from a distinguished panel of experts.

This committee sheds much-needed light on the questions and controversies surrounding unintended pregnancy. The book offers specific recommendations to put the United States on par with other developed nations in terms of contraceptive attitudes and policies, and it considers the effectiveness of over 20 pregnancy prevention programs.

The Best Intentions explores problematic definitions--"unintended" versus "unwanted" versus "mistimed"--and presents data on pregnancy rates and trends. The book also summarizes the health and social consequences of unintended pregnancies, for both men and women, and for the children they bear.

Why does unintended pregnancy occur? In discussions of "reasons behind the rates," the book examines Americans' ambivalence about sexuality and the many other social, cultural, religious, and economic factors that affect our approach to contraception. The committee explores the complicated web of peer pressure, life aspirations, and notions of romance that shape an individual's decisions about sex, contraception, and pregnancy. And the book looks at such practical issues as the attitudes of doctors toward birth control and the place of contraception in both health insurance and "managed care."

The Best Intentions offers frank discussion, synthesis of data, and policy recommendations on one of today's most sensitive social topics. This book will be important to policymakers, health and social service personnel, foundation executives, opinion leaders, researchers, and concerned individuals. May

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!