Contraception 77 (2008) 1 – 5
Editorial
Reducing unintended pregnancy in the United States
Almost half (49%) of all pregnancies in the United States
are unintended: There were 3.1 million in 2001 alone, the last
year for which data are available [1]. There has been no
change in the recent past; these statistics were the same in
1994 [2]. One of every two women aged 15–44 in the United
States has experienced at least one unintended pregnancy [2].
What is responsible for the unacceptably high incidence
of unintended pregnancy and what can be done to reduce
this incidence?
Information on levels and trends in contraceptive use in
the United States is based on the National Surveys of
Family Growth (NSFG), periodic surveys conducted by the
National Center for Health Statistics in which women ages
15–44 are interviewed about topics related to childbearing,
family planning and maternal and child health. Among the
61.6 million women of reproductive age in 2002, about 62%
(38.1 million) were using some method of contraception,
according to the 2002 NSFG. Among the 38% (23.5 million)
who were not currently using a method, only about one fifth
were at risk of pregnancy. The remaining four fifths were not
at risk because they had been sterilized for noncontraceptive
reasons, were sterile, were trying to become pregnant, were
pregnant, were interviewed within 2 months after the
completion of a pregnancy or were not having intercourse
during the 3 months prior to the survey [3].
As can be seen in Table 1 [4], almost 90% of the women at
risk for an unintended pregnancy were using a contraceptive
method. Today, the most popular contraceptive methods are
oral contraceptive pills (11.6 million users), female sterilization (10.3 million users), male condoms (6.8 million users)
and male sterilization (3.5 million users) [3]. Yet, even with
the majority of women at risk for unintended pregnancy using
some form of contraception, 10.7% of all women at risk were
not using any contraceptive method. The mix of methods
shown in Table 1 resulted in the staggering 3.1 million
unintended pregnancies in 2001; less than half (48%) of these
unintended pregnancies result from contraceptive failure,
with 52% of unintended pregnancies contributed by the
10.7% of women who use no method at all [1].
In Table 2 [5], we show estimates of contraceptive failure
rates in the United States. Pregnancy rates during typical use
show how effective the different methods are during actual
use (including inconsistent or incorrect use). Pregnancy rates
during perfect use show how effective methods can be,
0010-7824/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.contraception.2007.09.001
where perfect use is defined as following the directions for
use; for many methods, perfect use requires use at every act
of intercourse. The difference between pregnancy rates
during imperfect use and pregnancy rates during perfect use
reveals how forgiving of imperfect use a method is. Scrutiny
of Table 2 reveals four important findings:
1. The most effective methods during typical use are
generally those not requiring adherence.
2. Methods requiring adherence generally show a big
difference between perfect-use and typical-use failure rates.
3. Even the least effective methods are much more
effective than no method at all.
4. The most effective methods do not protect against
sexually transmitted infections.
Comparison of Tables 1 and 2 shows clearly that the most
effective long-acting reversible contraceptives — those not
requiring adherence [intrauterine devices (IUDs) and
implants] — are not used very frequently. Implanon was
not approved by the Food and Drug Administration (FDA)
until mid-2006 and, thus, could not appear in Table 1, but
Norplant, which is no longer marketed, was used by only
1.3% of women at risk of pregnancy in 1995 [6]. This
comparison, therefore, suggests three strategies for reducing
unintended pregnancy:
1. Increasing contraceptive use among those not using
a method.
2. Tipping the balance between those using effective
methods that do not require adherence and those that
do, so that relatively more people are relying on
methods that do not require adherence at every act of
vaginal intercourse to be effective [7].
3. Simultaneous use of condoms and a more
effective method among those at risk of sexually
transmitted infection.
Table 2 also suggests that widespread use of emergency
contraceptive pills (ECPs) could help to reduce unintended
pregnancy after no method was used, a condom broke or
slipped off the penis or several oral contraceptive pills were
missed. What is the potential for increasing ECP usage? In
the past two decades, researchers have evaluated numerous
interventions intended to accomplish this goal, including
2
Editorial / Contraception 77 (2008) 1–5
Table 1
Percentage and number of at-risk women and percentage of at-risk women currently using various methods from the 2002 NSFG
Percentage of at-risk women using a contraceptive method
Contraceptive method
Age range (years)
15–44
15–19
20–24
25–29
30–34
35–39
40–44
Pill
Female sterilization
Condom
No method
Male sterilization
Depo-Provera
Withdrawal
IUD
Fertility-awareness-based methods
Calendar rhythm
Implant, Lunelle or patch
Other methods a
Diaphragm
Spermicides
27.2
24.1
16.0
10.7
8.2
4.8
3.6
1.9
1.3
1.0
1.2
0.6
0.3
0.3
43.5
0.0
22.1
18.0
0.0
11.4
2.1
0.2
0.0
0.0
1.0
1.0
0.0
0.5
46.1
3.2
20.2
12.1
0.7
8.8
4.5
1.6
1.1
1.1
1.3
0.1
0.1
0.1
33.7
13.5
18.4
10.5
3.7
5.8
6.9
3.3
0.9
0.4
2.2
0.4
0.4
0.1
28.6
24.9
15.5
9.2
8.4
3.8
3.4
2.8
1.5
1.2
1.2
0.1
0.2
0.4
16.8
37.2
14.1
9.8
12.8
1.8
3.1
1.3
1.8
1.4
0.7
0.4
0.0
0.3
10.0
45.8
10.5
8.8
16.8
1.5
1.3
1.0
2.0
1.5
0.3
1.2
0.5
0.3
Number of women in the cohort as well as percentage and number of at-risk women
Number of women (in millions)
61.6
9.8
9.8
Percentage of at-risk women
69.4
38.4
69.2
Number of at-risk women (in millions)
42.7
3.8
6.8
9.2
76.0
7.0
10.3
76.2
7.8
10.9
78.6
8.5
11.5
75.9
8.7
At-risk women are those who either are current contraceptive users or are nonusers who have had sex in the past 3 months and are not trying to become pregnant,
are not pregnant or were not interviewed within 2 months after the completion of a pregnancy and are not sterile. Percentages may not add to 100 due to rounding.
Source: Ref. [4].
a
Other methods include cervical cap, sponge and female condom.
promotional campaigns, provision of ECPs in advance of
need, distribution by pharmacists or over the counter and
prescription by telephone [8­22]. Most of these interventions have increased ECP use — some substantially — but
whether any of these increases were sizeable enough to
produce a large public health effect is doubtful. Almost all
the studies that collected data on ECP use found that only a
minority of women exposed to the intervention ever used
ECPs, and few of those who became pregnant had tried to
prevent the pregnancy using ECPs. No study to date has yet
directly shown that any intervention has actually reduced
pregnancy rates [23­25]. It seems unlikely that EC will ever
have a dramatic public health impact.
Clearly, the strategies suggested above, including widespread use of ECPs, would have the intended effect of
reducing unintended pregnancy if they were successfully
implemented. However, family planning providers have
long encouraged and promoted use of contraception, use of
the most effective methods and use of ECPs with no
apparent success.
What makes a difference in unintended pregnancy
rates?
Debates that frame the problem of unintended pregnancy
in terms of what family planning providers can do leave out
an important part of the picture. Although advances in
technology in the form of long-acting reversible methods
not requiring adherence may be helpful, as might the
development of hormonal contraceptive methods for men,
technology alone is not sufficient. Many policies discourage consistent, effective contraceptive use and deserve to
be reconsidered.
For example, consider cost. Medicaid covers contraceptive supplies and services for poor women, and the
federal government covers contraceptive supplies and
services for its employees and their dependents. Yet, there
is considerable variability in contraceptive coverage by
private insurers. In 2002, almost every reversible contraceptive supply and service was covered by at least 89% of
private insurance plans, and 86% of plans covered the five
most popular prescription contraceptives [26]. Breaking
down those figures further, we see that legislative policy
makes a difference in the extent to which contraceptives are
covered by private insurance. Twenty-six states require
private-sector insurers that cover prescription drugs to
provide coverage for prescription contraceptives and related
services [27]; these mandates do not apply to the half of
employees who have insurance through employers that selfinsure [26]. In those states, plans were much more likely to
cover the five leading prescription contraceptives (87–92%
vs. 47–61%) [26].
Although there has been considerable improvement in
coverage of contraceptive supplies and services in the United
States, some women are still not covered, and for many who
are, the co-pays and deductibles constitute a considerable
economic burden. When Kaiser Permanente Northern
California eliminated the co-pay for the most effective
Editorial / Contraception 77 (2008) 1–5
3
Table 2
Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the
percentage of women continuing use at the end of the first year, United States
Method
Percentage of women experiencing an
unintended pregnancy within the first year
of use
d
No method
Spermicides e
Withdrawal
Fertility-awareness-based methods
Standard days method f
TwoDay method f
Ovulation method f
Sponge
Parous women
Nulliparous women
Diaphragm g
Condom h
Female (Reality)
Male
Combined pill and progestin-only pill
Evra patch
NuvaRing
Depo-Provera
IUD
ParaGard (copper T)
Mirena (LNG-IUS)
Implanon
Female sterilization
Male sterilization
Typical use b
Perfect use c
85
29
27
25
85
18
4
Percentage of women
continuing use at 1 year a
42
43
51
5
4
3
32
16
16
21
15
8
8
8
3
0.8
0.2
0.05
0.5
0.15
20
9
6
46
57
57
5
2
0.3
0.3
0.3
0.3
49
53
68
68
68
56
0.6
0.2
0.05
0.5
0.10
78
80
84
100
100
Emergency Contraceptive Pills: Treatment initiated within 72 h after unprotected intercourse reduces the risk of pregnancy by at least 75%. i
Lactational Amenorrhea Method: It is a highly effective, temporary method of contraception. j
Source: Ref. [5].
a
Among couples attempting to avoid pregnancy, the percentage who continue to use a method for 1 year.
b
Among typical couples who initiate use of a method (not necessarily for the first time), the percentage who experience an accidental pregnancy during the
first year if they do not stop use for any other reason. Estimates of the probability of pregnancy during the first year of typical use for spermicides, withdrawal,
fertility awareness-based methods, the diaphragm, the male condom, the pill and Depo-Provera are taken from the 1995 NSFG corrected for underreporting of
abortion; see the reference above for the derivation of estimates for the other methods.
c
Among couples who initiate use of a method (not necessarily for the first time) and who use it perfectly (both consistently and correctly), the percentage
who experience an accidental pregnancy during the first year if they do not stop use for any other reason. For the derivation of the estimate for each method, see
the reference above.
d
The percentages becoming pregnant in Columns 2 and 3 are based on data from populations where contraception is not used and from women who cease
using contraception in order to become pregnant. Among such populations, about 89% become pregnant within 1 year. This estimate was lowered slightly (to
85%) to represent the percentage who would become pregnant within 1 year among women now relying on reversible methods of contraception if they
abandoned contraception altogether.
e
Foams, creams, gels, vaginal suppositories and vaginal film.
f
The Ovulation and TwoDay methods are based on evaluation of cervical mucus. The Standard Days method avoids intercourse on Cycle Days 8–19.
g
With spermicidal cream or jelly.
h
Without spermicides.
i
The treatment schedule is one dose within 120 h after unprotected intercourse and a second dose 12 h after the first dose. Both doses of Plan B can be
taken at the same time. Plan B (one dose is one white pill) is the only dedicated product specifically marketed for emergency contraception. The FDA has, in
addition, declared the following 22 brands of oral contraceptives to be safe and effective for emergency contraception: Ogestrel or Ovral (one dose is two white
pills); Levlen or Nordette (one dose is four light orange pills), Cryselle, Levora, Low-Ogestrel, Lo/Ovral or Quasence (one dose is four white pills); Tri-Levlen
or Triphasil (one dose is four yellow pills); Jolessa, Portia, Seasonale or Trivora (one dose is four pink pills); Seasonique (one dose is four light blue-green
pills); Empresse (one dose is four orange pills); Alesse, Lessina or Levlite (one dose is five pink pills); Aviane (one dose is five orange pills); and Lutera (one
dose is five white pills).
j
However, to maintain effective protection against pregnancy, another method of contraception must be used as soon as menstruation resumes, the
frequency or duration of breast-feeds is reduced, bottle feeds are introduced or the baby reaches 6 months of age.
forms of contraception (intrauterine contraceptives, injectables), couple-years of protection increased 28% while the
caseload of females aged 15–44 fell by 1%. Couple-years of
protection for intrauterine contraceptives and injectables rose
137% and 32%, respectively, while couple-years of protection for the pill, patch and ring rose only 16% [28].
Coverage rules that impede consistent use also deserve
attention. A delay in obtaining a needed contraceptive refill
4
Editorial / Contraception 77 (2008) 1–5
may result in significant reduction of contraceptive efficacy
and is a very common reason for contraceptive failure.
Yet, many insurance plans require women to fill prescriptions for contraception on a monthly basis. Because
pregnancy is so expensive, marginal savings gained by
limiting refill access are almost certain to be overwhelmed
by added costs of pregnancy caused by reduced contraceptive effectiveness.
Lending weight to our suspicion that rates of unintended
pregnancy are linked to both cost and access to medical care,
recent analysis has shown that both unplanned pregnancies
and abortions in the United States are closely linked to
women's socioeconomic status. Poor women are four times
as likely to have an unintended pregnancy as higher-income
women and three times as likely to have an abortion [1].
Reducing unintended pregnancy is a formidable challenge. There is no magic bullet, and there will always be a
group of women and men who have unprotected sex or
whose contraceptive methods fail.
Yet, a quick look at the rate of unintended pregnancy in
other countries suggests that the problem is not simply one
of ‘human nature’ or a matter of the limitations of existing
contraceptive technologies. While 49% of pregnancies in
the United States are unintended, the corresponding
percentage in France is only 33% [29], and in Edinburgh,
Scotland, it is only 28% [30,31]. Compared with the United
States, these countries have much lower proportions of
women at risk for unintended pregnancy who use no
contraception at all; while this figure is 11% in the United
States, it is only 3% in France and 3% in the United
Kingdom [29,32]. Moreover, IUD use is much more
common; while only 2% of women at risk use IUDs in
the United States, 6% use IUDs in the United Kingdom and
20% use IUDs in France [29,32].
No matter how dedicated they are, family planning
providers cannot fix such structural problems. Instead, policy
interventions are needed on a broader scale. Two examples
illustrate this approach. In early 2007, Senator Harry Reid
(D-NV) and Representative Louise Slaughter (D-NY)
reintroduced the Prevention First Act, an omnibus piece of
legislation that would help prevent unintended pregnancies
by expanding women's access to contraception and young
people's access to sex education. In addition, Senator Hilary
Rodham Clinton (D-NY) and Representative Nita Lowey
(D-NY) recently introduced the Unintended Pregnancy
Reduction Act to ensure that low-income women across
the country have equal access to contraceptive services and
equal access to pregnancy-related care if they do become
pregnant. Essentially, it would guarantee that the same
women who have access to Medicaid-funded pregnancy care
would also have access to contraceptive services and
supplies [33]. Two analyses suggest that not only would
this change serve women by ensuring that they have greater
access to medical care and control over their reproductive
lives, it would also result in reduced birth rates and
significant public-sector cost savings [33­35].
James Trussell
Office of Population Research, Wallace Hall
Princeton University, Princeton NJ 08544, USA
E-mail address: [email protected]
L.L. Wynn
Department of Anthropology
Macquarie University, NSW 2109, Australia
E-mail address: [email protected]
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