Contraceptive Use Among Women at Risk for Unintended Pregnancy in the Context of Public Health Emergencies — United States, 2016

Karen Pazol, PhD; Sascha R. Ellington, MSPH; Anna C. Fulton, MPH; Lauren B. Zapata, PhD; Sheree L. Boulet, DrPH; Marion E. Rice, MPH; Shanna Cox, MSPH; Lisa Romero, DrPH; Eva Lathrop, MD; Stacey Hurst, MPH; Charlan D. Kroelinger, PhD; Howard Goldberg, PhD; Carrie K. Shapiro-Mendoza, PhD; Regina M. Simeone, MPH; Lee Warner, PhD; Dana M. Meaney-Delman, MD; Wanda D. Barfield, MD

Disclosures

Morbidity and Mortality Weekly Report. 2018;67(32):898-902. 

In This Article

Abstract and Introduction

Introduction

Ensuring access to and promoting use of effective contraception have been identified as important strategies for preventing unintended pregnancy.[1] The importance of ensuring resources to prevent unintended pregnancy in the context of public health emergencies was highlighted during the 2016 Zika virus outbreak when Zika virus infection during pregnancy was identified as a cause of serious birth defects.[2] Accordingly, CDC outlined strategies for state, local, and territorial jurisdictions to consider implementing to ensure access to contraception.[3] To update previously published contraceptive use estimates* among women at risk for unintended pregnancy and to estimate the number of women with ongoing or potential need for contraceptive services,§,¶ data on contraceptive use were collected during September–December 2016 through the Behavioral Risk Factor Surveillance System (BRFSS). Results from 21 jurisdictions indicated that most women aged 18–49 years were at risk for unintended pregnancy (range across jurisdictions = 57.4%–76.8%). Estimates of the number of women with ongoing or potential need for contraceptive services ranged from 368 to 617 per 1,000 women aged 18–49 years. The percentage of women at risk for unintended pregnancy using a most or moderately effective contraceptive method** ranged from 26.1% to 65.7%. Jurisdictions can use this information to estimate the number of women who might seek contraceptive services and to plan and evaluate efforts to increase contraceptive use. This information is particularly important in the context of public health emergencies, such as the recent Zika virus outbreak, which have been associated with increased risk for adverse maternal-infant outcomes[2,4–6] and have highlighted the importance of providing women and their partners with resources to prevent unintended pregnancy.

BRFSS is a cross-sectional jurisdiction-specific, random-digit–dialed, telephone survey that collects data on risk behaviors and preventive health practices among adult respondents living in the 50 states, the District of Columbia, Puerto Rico, Guam, and U.S. Virgin Islands.†† This report includes data from 21 jurisdictions§§ that implemented the optional family planning module on self-reported contraceptive use during September–December 2016.¶¶ Individual contraceptive methods from this module were classified according to first-year typical use failure rates as most effective (≤1% failure), moderately effective (>1%–10% failure), or less effective (>10% failure).*** Women reporting more than one contraceptive method were classified according to the most effective method they reported using.

Weighted estimates and 95% confidence intervals were calculated to determine the proportion of women aged 18–49 years at risk for unintended pregnancy (defined as those who reported they were sexually active with a male partner, but did not report that they were currently pregnant or seeking pregnancy, that they would not mind being pregnant, or that they had a hysterectomy). In addition, numbers and rates (total number and number per 1,000 women aged 18–49 years) and corresponding 95% confidence intervals were calculated for women with ongoing or potential need for contraceptive services (defined as those at risk for unintended pregnancy who were not using permanent contraceptive methods [female sterilization or report of male partner vasectomy]). Estimates also were calculated to describe the proportion of women at risk for unintended pregnancy using contraception by effectiveness category (most effective, including permanent methods and long-acting reversible contraception [LARC]; moderately effective; less effective; and no method). Estimates for using either a less effective method or no method were further stratified by age group (18–24, 25–34, 35–44, and 45–49 years). Women at risk for unintended pregnancy who did not specify the type of contraception they used or reported "other" methods (4.8%)††† were excluded from estimates of contraceptive use by method effectiveness and from estimates of the number of women with ongoing or potential need for contraceptive services. Estimates that did not meet reliability standards established for BRFSS were suppressed.§§§

Among the 21 jurisdictions, the proportion of women aged 18–49 years at risk for unintended pregnancy ranged from 57.4% (Texas) to 76.8% (Minnesota) (Table 1). Jurisdictions with the fewest numbers of women with ongoing or potential need for contraceptive services included Guam, Kansas, Puerto Rico, and West Virginia; jurisdictions with the highest numbers included California, Florida, Illinois, and Texas. Estimates of the number of women with ongoing or potential need for contraceptive services per 1,000 women aged 18–49 years ranged from 368 in Puerto Rico to 617 in Maryland. Among women at risk for unintended pregnancy, the proportion using either a most or moderately effective contraceptive method ranged from 26.1% (Guam) to 65.7% (West Virginia) (Table 2); among 11 jurisdictions with reliable estimates for LARC, use ranged from 5.5% (Kansas) to 17.0% (Maryland). Among 18 jurisdictions with reliable estimates, the percentage of women at risk for unintended pregnancy using a less effective method of contraception ranged from 11.1% (Illinois) to 47.7% (Arizona), and among 19 jurisdictions, the percentage not using any method of contraception ranged from 16.5% (Virginia) to 63.0% (Guam) (Table 3). Across age-stratified estimates, the percentage using either a less effective method or no method ranged from 25.9% (women aged 35–44 years in South Carolina) to 79.9% (women aged 18–24 years in California) (Supplementary Table, https://stacks.cdc.gov/view/cdc/57915).

*State-based estimates of contraceptive use during the Zika response were from 2011–2013. https://www.cdc.gov/mmwr/volumes/65/wr/mm6530e2.htm.
Women were considered at risk for unintended pregnancy unless they reported that they were not sexually active with a male partner, that they were currently pregnant or seeking pregnancy, that they would not mind being pregnant, or that they had a hysterectomy.
§Women with ongoing or potential need for contraceptive services were defined as those women considered at risk for unintended pregnancy who were not using permanent contraceptive methods (female sterilization or report of male partner vasectomy).
The number of women with ongoing or potential need for contraceptive services can be used to predict the number of women who might seek services, but does not represent unmet need for contraception because many of these women might already be using some method of contraception. https://www.guttmacher.org/sites/default/files/report_pdf/contraceptive-needs-and-services-2014_1.pdf.
**Most effective contraceptive methods are associated with a ≤1% failure rate during the first year of typical use; moderately effective contraceptive methods are associated with a >1%–10% failure rate during the first year of typical use. These contrast with less effective methods, which are associated with a >10% failure rate during the first year of typical use, and the use of no method, which is associated with an 85% pregnancy rate for the overall population of women of reproductive age. https://www.cdc.gov/reproductivehealth/contraception/index.htm.
†† https://www.cdc.gov/brfss/data_documentation/index.htm.
§§Includes Alabama, Arizona, California, Connecticut, Florida, Georgia, Illinois, Kansas, Kentucky, Louisiana, Maryland, Minnesota, New Jersey, Ohio, Oklahoma, South Carolina, Texas, Virginia, West Virginia, Guam, and Puerto Rico. Data collected for Mississippi are not included in this report because they did not meet BRFSS reliability standards (denominators ≥50 respondents and a relative standard error ≤30%) with respect to reporting the number of women with ongoing or potential need for contraceptive services, or the proportion of women at risk for unintended pregnancy by method type.
¶¶Questions implemented followed those implemented in 2017 with Module 17: Preconception Health/Family Planning. https://www.cdc.gov/brfss/questionnaires/pdf-ques/2017_BRFSS_Pub_Ques_508_tagged.pdf.
***Most effective contraceptive methods included permanent contraceptive methods (female sterilization or report of male partner vasectomy) and long-acting reversible contraception (LARC, including intrauterine devices [IUDs] and contraceptive implants). Moderately effective contraceptive methods included contraceptive injectables, contraceptive pills, contraceptive patches, and vaginal rings. Less effective contraceptive methods included diaphragms, condoms (male or female), withdrawal, cervical caps, sponges, spermicides, fertility-awareness based methods, and emergency contraception.
†††Write-in responses were not available for women responding "other," and previous evaluation of BRFSS contraceptive use data indicates these methods are a mix of permanent and reversible methods of all effectiveness levels. https://www.cdc.gov/mmwr/volumes/65/wr/mm6530e2.htm.
§§§Reliability standards for BRFSS require suppression of estimates with an unweighted denominator of <50 respondents or a relative standard error >30%.

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