Declines in Unintended Pregnancy in the United States, 2008-2011.

BACKGROUND: The rate of unintended pregnancy in the United States increased slightly between 2001 and 2008 and is higher than that in many other industrialized countries. National trends have not been reported since 2008. METHODS: We calculated rates of pregnancy for the years 2008 and 2011 according to women's and girls' pregnancy intentions and the outcomes of those pregnancies. We obtained data on pregnancy intentions from the National Survey of Family Growth and a national survey of patients who had abortions, data on births from the National Center for Health Statistics, and data on induced abortions from a national census of abortion providers; the number of miscarriages was estimated using data from the National Survey of Family Growth. RESULTS: Less than half (45%) of pregnancies were unintended in 2011, as compared with 51% in 2008. The rate of unintended pregnancy among women and girls 15 to 44 years of age declined by 18%, from 54 per 1000 in 2008 to 45 per 1000 in 2011. Rates of unintended pregnancy among those who were below the federal poverty level or cohabiting were two to three times the national average. Across population subgroups, disparities in the rates of unintended pregnancy persisted but narrowed between 2008 and 2011; the incidence of unintended pregnancy declined by more than 25% among girls who were 15 to 17 years of age, women who were cohabiting, those whose incomes were between 100% and 199% of the federal poverty level, those who did not have a high school education, and Hispanics. The percentage of unintended pregnancies that ended in abortion remained stable during the period studied (40% in 2008 and 42% in 2011). Among women and girls 15 to 44 years of age, the rate of unintended pregnancies that ended in birth declined from 27 per 1000 in 2008 to 22 per 1000 in 2011. CONCLUSIONS: After a previous period of minimal change, the rate of unintended pregnancy in the United States declined substantially between 2008 and 2011, but unintended pregnancies remained most common among women and girls who were poor and those who were cohabiting. (Funded by the Susan Thompson Buffett Foundation and the National Institutes of Health.).

Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program.

UNLABELLED: Policy Points: The US publicly supported family planning effort serves millions of women and men each year, and this analysis provides new estimates of its positive impact on a wide range of health outcomes and its net savings to the government. The public investment in family planning programs and providers not only helps women and couples avoid unintended pregnancy and abortion, but also helps many thousands avoid cervical cancer, HIV and other sexually transmitted infections, infertility, and preterm and low birth weight births. This investment resulted in net government savings of $13.6 billion in 2010, or $7.09 for every public dollar spent. CONTEXT: Each year the United States' publicly supported family planning program serves millions of low-income women. Although the health impact and public-sector savings associated with this program's services extend well beyond preventing unintended pregnancy, they never have been fully quantified. METHODS: Drawing on an array of survey data and published parameters, we estimated the direct national-level and state-level health benefits that accrued from providing contraceptives, tests for the human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs), Pap tests and tests for human papillomavirus (HPV), and HPV vaccinations at publicly supported family planning settings in 2010. We estimated the public cost savings attributable to these services and compared those with the cost of publicly funded family planning services in 2010 to find the net public-sector savings. We adjusted our estimates of the cost savings for unplanned births to exclude some mistimed births that would remain publicly funded if they had occurred later and to include the medical costs for births through age 5 of the child. FINDINGS: In 2010, care provided during publicly supported family planning visits averted an estimated 2.2 million unintended pregnancies, including 287,500 closely spaced and 164,190 preterm or low birth weight (LBW) births, 99,100 cases of chlamydia, 16,240 cases of gonorrhea, 410 cases of HIV, and 13,170 cases of pelvic inflammatory disease that would have led to 1,130 ectopic pregnancies and 2,210 cases of infertility. Pap and HPV tests and HPV vaccinations prevented an estimated 3,680 cases of cervical cancer and 2,110 cervical cancer deaths; HPV vaccination also prevented 9,000 cases of abnormal sequelae and precancerous lesions. Services provided at health centers supported by the Title X national family planning program accounted for more than half of these benefits. The gross public savings attributed to these services totaled approximately $15.8 billion-$15.7 billion from preventing unplanned births, $123 million from STI/HIV testing, and $23 million from Pap and HPV testing and vaccines. Subtracting $2.2 billion in program costs from gross savings resulted in net public-sector savings of $13.6 billion. CONCLUSIONS: Public expenditures for the US family planning program not only prevented unintended pregnancies but also reduced the incidence and impact of preterm and LBW births, STIs, infertility, and cervical cancer. This investment saved the government billions of public dollars, equivalent to an estimated taxpayer savings of $7.09 for every public dollar spent.

Shifts in intended and unintended pregnancies in the United States, 2001-2008.

OBJECTIVES: We monitored trends in pregnancy by intendedness and outcomes of unintended pregnancies nationally and for key subgroups between 2001 and 2008. METHODS: Data on pregnancy intentions from the National Survey of Family Growth (NSFG) and a nationally representative survey of abortion patients were combined with counts of births (from the National Center for Health Statistics), counts of abortions (from a census of abortion providers), estimates of miscarriages (from the NSFG), and population denominators from the US Census Bureau to obtain pregnancy rates by intendedness. RESULTS: In 2008, 51% of pregnancies in the United States were unintended, and the unintended pregnancy rate was 54 per 1000 women ages 15 to 44 years. Between 2001 and 2008, intended pregnancies decreased and unintended pregnancies increased, a shift previously unobserved. Large disparities in unintended pregnancy by relationship status, income, and education increased; the percentage of unintended pregnancies ending in abortion decreased; and the rate of unintended pregnancies ending in birth increased, reaching 27 per 1000 women. CONCLUSIONS: Reducing unintended pregnancy likely requires addressing fundamental socioeconomic inequities, as well as increasing contraceptive use and the uptake of highly effective methods.

Effect of mifepristone on abortion access in the United States.

OBJECTIVE: To examine the pattern of mifepristone uptake in the United States and whether the introduction of this drug has facilitated access to abortion services. METHODS: Using data from a national census of abortion providers and from the U.S. distributor of mifepristone, we assessed the number and proportion of abortions performed using mifepristone, the distribution of mifepristone providers by provider type and medical specialty, and the geographic distribution of mifepristone and surgical providers. RESULTS: The number of mifepristone providers increased from 208 in the last 2 months of 2000 to 700 in 2001, the first full year of availability, and to 902 in 2007. Some 158,000 mifepristone abortions were performed in 2007, representing an estimated 14% of all abortions and 21% of eligible early abortions. Physicians represented 51% of mifepristone providers but accounted for just 11% of abortions; most were obstetrician-gynecologists. The proportion of abortions in each state performed using mifepristone ranged from 0% to 80%. Most mifepristone abortions were performed at or near facilities that also provided surgical abortion. Only five mifepristone-only providers of 10 or more abortions were located farther than 50 miles from any surgical provider of 400 or more abortions. CONCLUSION: Mifepristone has become an integral part of abortion provision in the United States and likely has contributed to a trend toward very early abortions. However, expectations that approval of mifepristone would result in a wider range of providers offering abortion have not yet been met, and mifepristone has not brought a major improvement in the geographic availability of abortion. LEVEL OF EVIDENCE: III.

Trends in abortion in the United States.

The US abortion rate peaked soon after 1973, remained fairly constant through the 1980s, and began a steady decline to 2005. A substantial drop in the abortion rates of teenagers and women ages 20 to 24 accounts for much of the decline from 1989 to 2004. All race and ethnic groups experienced declines in abortion rates over the past 30 years, but the rate of black, and to a lesser extent Hispanic, women remains higher than that of non-Hispanic whites. The number of abortion providers has declined in recent decades, but the introduction of early medical abortion may have slowed this trend.

Abortion in the United States: incidence and access to services, 2005.

CONTEXT: Accurate information about abortion incidence and services is necessary to monitor levels of unwanted pregnancy and women's ability to access abortion services. METHODS: All known abortion providers in the United States were contacted for information about abortion services in 2004 and 2005. This information, along with data from the U.S. Census Bureau, was used to examine national and state trends in numbers of abortions and abortion rates, proportions of counties and metropolitan areas without an abortion provider, and accessibility of abortion services. RESULTS: An estimated 1.2 million abortions were performed in the United States in 2005, 8% fewer than in 2000. The abortion rate in 2005 was 19.4 per 1,000 women aged 15-44; this rate represents a 9% decline from 2000. There were 1,787 abortion providers in 2005, only 2% fewer than in 2000. Some 87% of U.S. counties, containing 35% of women aged 15-44, did not have an abortion provider in 2005. Early medication abortion, offered by an estimated 57% of known providers, accounted for 13% of abortions (and for 22% of abortions before nine weeks' gestation). The average amount paid for an abortion at 10 weeks was $413-after adjustment for inflation, $11 less than in 2001. CONCLUSION: The numbers of abortions and the abortion rate continued their long-term decline through 2005. Reasons for this trend are unknown but may include improved access to and use of contraceptives or decreased access to abortion services.

Comparability of contraceptive prevalence etimates for women from the 2002 Behavioral Risk Factor Surveillance System.

OBJECTIVE: This article assesses the comparability of contraceptive use estimates for adult women obtained from the 2002 Behavioral Risk Factor Surveillance System (BRFSS), using the 2002 National Survey of Family Growth (NSFG) as a benchmark. The 2002 BRFSS uses data collection methods that are considerably different from the NSFG. METHOD: We compared demographic differences and national estimates of current contraceptive methods being used and reasons for nonuse. Variables were recoded in the BRFSS and NSFG systems to make the two samples comparable. RESULTS: Women in the NSFG and BRFSS were similar in age and race/ethnicity. Compared with the NSFG, the BRFSS sample was more educated and of higher income, less likely to be cohabiting, and more likely to be married. After adjusting for differences in the coding of hysterectomy, many BRFSS estimates for current contraceptive use were statistically similar to those from the NSFG. Small but statistically significant differences were found for vasectomy (7.7% and 6.3%), the pill (21.9% and 19.6%), rhythm (1.5% and 1.0%), the diaphragm (0.5% and 0.2%), and withdrawal (0.3% and 2.7%) for the BRFSS and NSFG, respectively. Major reasons for nonuse were similar: seeking pregnancy and currently pregnant. The percentage of women who were not currently sexually active was higher in the BRFSS (16.0%) compared with the NSFG (12.5%). CONCLUSIONS: The BRFSS is a useful source of population-based data on contraceptive use for reproductive health program planning; however, planners should be cognizant that lower-income women are not fully represented in telephone surveys.

The impact of publicly funded family planning clinic services on unintended pregnancies and government cost savings.

Publicly funded family planning clinics serve millions of low-income women each year, providing a range of critical preventive services and enabling women to avoid unintended pregnancies. It is important to quantify the impact and cost-effectiveness of such services, in addition to these health benefits. Using a methodology similar to prior cost-benefit analyses, we estimated the numbers of unintended pregnancies prevented by all U.S. publicly funded family planning clinics in 2004, nationally (1.4 million pregnancies) and for each state. We also compared the actual costs of providing these services ($1.4 billion) with the anticipated public-sector costs for maternity and infant care among the Medicaid-eligible women whose births were averted ($5.7 billion) to calculate net public-sector savings ($4.3 billion). Thus, public expenditures for family planning care not only help women to achieve their childbearing goals, but they also save public dollars: Our calculations indicate that for every $1 spent, $4.02 is saved.

A prospective measure of unintended pregnancy in the United States.

OBJECTIVE: To describe a new measure, the unintended pregnancy risk index (UPRI), which is based primarily on attitudinal and behavioral measures of women's prospective pregnancy desire, and compare it to the unintended pregnancy rate, typically calculated retrospectively. STUDY DESIGN: We used three rounds of the National Survey of Family Growth to calculate trends in the UPRI and compare it to the retrospective rate. The UPRI estimates the annual risk of becoming unintentionally pregnant on a scale from 0 to 100. It is based on women's prospective pregnancy desire as well as fecundity, sexual activity and contraceptive use patterns. RESULTS: Among all women aged 15-34, the UPRI ranged from 7.4 in 2002 to 5.7 in 2013. The retrospective unintended pregnancy rate had similar levels and declines for the same overall period, although the UPRI declined earlier than the retrospective rate. CONCLUSIONS: Changes in the use of any contraceptive method, the methods used and the effectiveness of the methods used all contributed to the decline in the UPRI. IMPLICATIONS: The sufficiency of retrospective measures of pregnancy intention has been challenged, and data availability has constrained needed surveillance of the unintended pregnancy rate. The UPRI offers a new measure that can be calculated with existing national surveillance data or for any population for which data on prospective pregnancy desire, pregnancy risk and contraceptive use are available.

Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use.

OBJECTIVES: We explored the relative contributions of declining sexual activity and improved contraceptive use to the recent decline in adolescent pregnancy rates in the United States. METHODS: We used data from 1995 and 2002 for women 15 to 19 years of age to develop 2 indexes: the contraceptive risk index, summarizing the overall effectiveness of contraceptive use among sexually active adolescents (including nonuse), and the overall pregnancy risk index, calculated according to the contraceptive risk index score and the percentage of individuals reporting sexual activity. RESULTS: The contraceptive risk index declined 34% overall and 46% among adolescents aged 15 to 17 years. Improvements in contraceptive use included increases in the use of condoms, birth control pills, withdrawal, and multiple methods and a decline in nonuse. The overall pregnancy risk index declined 38%, with 86% of the decline attributable to improved contraceptive use. Among adolescents aged 15 to 17 years, 77% of the decline in pregnancy risk was attributable to improved contraceptive use. CONCLUSIONS: The decline in US adolescent pregnancy rates appears to be following the patterns observed in other developed countries, where improved contraceptive use has been the primary determinant of declining rates.

Factors associated with contraceptive use and nonuse, United States, 2004.

CONTEXT: Each year, nearly one in four U.S. women at risk of unintended pregnancy experience one or more months of contraceptive nonuse. Understanding what factors are associated with risky contraceptive use patterns can inform programs and policies designed to reduce levels of unintended pregnancy. METHODS: A nationally representative sample of 1,978 adult women at risk for unintended pregnancy was surveyed over the telephone in 2004. Respondents provided information on contraceptive use over the past 12 months. Multiple logistic regressions were used to identify factors associated with different contraceptive use patterns. RESULTS: Ambivalence about avoiding pregnancy was strongly associated with both contraceptive nonuse and having a gap in use while remaining at risk of unintended pregnancy (odds ratios, 2.4 and 2.0, respectively). Other significant predictors of either of these risky contraceptive behaviors were having less than a college education, being black, being 35-44 years old, having infrequent sexual intercourse, not being in a current relationship, being dissatisfied with one's method and believing that contraceptive service providers were not available to answer method-related questions (1.7-3.8). CONCLUSIONS: Providers could better help women avoid unintended pregnancy by initiating regular assessments of method use difficulties, improving counseling on method choice and pregnancy risk, and identifying and assisting women at higher risk for inconsistent method use because of disadvantage, relationship characteristics or ambivalence about pregnancy prevention. In addition to providers' efforts, broader societal commitment is critical for increasing contraceptive knowledge and expanding access to contraceptive care for all women who are at risk of having an unintended pregnancy.

U.S. women's one-year contraceptive use patterns, 2004.

CONTEXT: Unintended pregnancies occur far too often in the United States, and half occur when couples fail to practice contraception. Improved measures of the continuity of women's contraceptive use, nonuse and switching patterns can help identify ways to reduce unintended pregnancy. METHODS: A nationally representative sample of 1,978 adult women at risk of unintended pregnancy was surveyed by telephone in 2004. Respondents provided detailed information about contraceptive use and periods of stopping or switching methods during the past year. A typology of patterns of contraceptive use was created, classifying women into mutually exclusive categories according to their exposure to pregnancy risk. RESULTS: Twenty-three percent of women at risk of unintended pregnancy were exposed to a high risk of pregnancy because of gaps in contraceptive method use in the year prior to the survey--8% were consistent nonusers, and 15% experienced 1-11 months of nonuse while at risk. More than half of women used a method during each of the previous 12 months-38% used the same method or methods all year, and 24% switched methods. Fifteen percent of women had gaps in contraceptive use when they were not at risk. Women reported a variety of reasons for their gaps in contraceptive use, including method-related difficulties and side effects, infrequent sex and being ambivalent about avoiding pregnancy. CONCLUSIONS: Strategies for reducing gaps in contraceptive use include improved counseling to help women both choose the right method and continue method use, especially when they have periods of infrequent sexual activity or are experiencing method-related side effects or problems.

Trends in premarital sex in the United States, 1954-2003.

OBJECTIVES: Policy and programmatic efforts promoting sexual abstinence until marriage have increased, but it is unclear whether establishing such behavior as normative is a realistic public health goal. This study examined the proportion of individuals in various cohorts who had had premarital sex (defined as either having had vaginal intercourse before first marrying or ever having had intercourse and never having married) by various ages. METHODS: Data from four cycles of the National Survey of Family Growth, 1982-2002, and event history analysis techniques, including Kaplan-Meier life-table procedures and Cox proportional-hazards regression models, were used to examine the incidence of premarital sex by gender and historical cohort. RESULTS: Data from the 2002 survey indicate that by age 20, 77% of respondents had had sex, 75% had had premarital sex, and 12% had married; by age 44, 95% of respondents (94% of women, 96% of men, and 97% of those who had ever had sex) had had premarital sex. Even among those who abstained until at least age 20, 81% had had premarital sex by age 44. Among cohorts of women turning 15 between 1964 and 1993, at least 91% had had premarital sex by age 30. Among those turning 15 between 1954 and 1963, 82% had had premarital sex by age 30, and 88% had done so by age 44. CONCLUSIONS: Almost all Americans have sex before marrying. These findings argue for education and interventions that provide the skills and information people need to protect themselves from unintended pregnancy and sexually transmitted diseases once they become sexually active, regardless of marital status.

Disparities in rates of unintended pregnancy in the United States, 1994 and 2001.

CONTEXT: Many pregnancies are unintended, particularly in certain population groups. Determining whether unintended pregnancy rates and disparities in rates between subgroups are changing may help policymakers target reproductive health services to those women most in need. METHODS: To calculate rates of unintended pregnancy and related outcomes, data on pregnancy intendedness from the 2002 National Survey of Family Growth were combined with birth, abortion and population data from federal, state and nongovernmental sources. RESULTS: In 2001, 49% of pregnancies in the United States were unintended. The unintended pregnancy rate was 51 per 1,000 women aged 15-44, meaning that 5% of this group had an unintended pregnancy. This level was unchanged from 1994. The rate of unintended pregnancy in 2001 was substantially above average among women aged 18-24, unmarried (particularly cohabiting) women, low-income women, women who had not completed high school and minority women. Between 1994 and 2001, the rate of unintended pregnancy declined among adolescents, college graduates and the wealthiest women, but increased among poor and less educated women. The abortion rate and the proportion of unintended pregnancies ending in abortion among all women declined, while the unintended birth rate increased. Forty-eight percent of unintended conceptions in 2001 occurred during a month when contraceptives were used, compared with 51% in 1994. CONCLUSIONS: More research is needed to determine the factors underlying the disparities in unintended pregnancy rates by income and other characteristics. The findings may reflect a need for increased and more effective contraceptive use, particularly among high-risk groups.

Timing of steps and reasons for delays in obtaining abortions in the United States.

OBJECTIVE: We studied the steps in the process of obtaining abortions and women's reported delays in order to help understand difficulties in accessing abortion services. METHODS: In 2004, a structured survey was completed by 1209 abortion patients at 11 large providers, and in-depth interviews were conducted with 38 women at four sites. RESULTS: The median time from the last menstrual period to suspecting pregnancy was 33 days; the median time from suspecting pregnancy to confirming the pregnancy was 4 days; the median time from confirming the pregnancy to deciding to have an abortion was 0 day; the median time from deciding to have an abortion to first attempting to obtain abortion services was 2 days; and the median time from first attempting to obtain abortion services to obtaining the abortion was 7 days. Minors took a week longer to suspect pregnancy than adults did. Fifty-eight percent of women reported that they would have liked to have had the abortion earlier. The most common reasons for delay were that it took a long time to make arrangements (59%), to decide (39%) and to find out about the pregnancy (36%). Poor women were about twice as likely to be delayed by difficulties in making arrangements. CONCLUSIONS: Financial limitations and lack of knowledge about pregnancy may make it more difficult for some women to obtain early abortion.

Changes in out-of-pocket costs for hormonal IUDs after implementation of the Affordable Care Act: an analysis of insurance benefit inquiries.

BACKGROUND: The Affordable Care Act (ACA) requires that privately insured women can obtain contraceptive services and supplies without cost sharing. This may substantially affect women who prefer an intrauterine device (IUD), a long-acting reversible contraceptive, because of high upfront costs that they would otherwise face. However, imperfect enforcement of and exceptions to this provision could limit its effect. STUDY DESIGN: We analyzed administrative data for 417,221 women whose physicians queried their insurance plans from January 2012 to March 2014 to determine whether each woman had insurance coverage for a hormonal IUD and the extent of that coverage. RESULTS: In January 2012, 58% of women would have incurred out-of-pocket costs for an IUD, compared to only 13% of women in March 2014. Differentials by age and region virtually dissolved over the period studied, which suggests that the ACA reduced inequality among insured women. CONCLUSIONS: Our findings suggest that the cost of hormonal IUDs fell to US$0 for most insured women following the implementation of the ACA. IMPLICATIONS: Financial barriers to one of the most effective methods of contraception fell substantially following the ACA. If more women interested in this method can access it, this may contribute to a decline in unintended pregnancies in the United States.

Reasons U.S. women have abortions: quantitative and qualitative perspectives.

CONTEXT: Understanding women's reasons for having abortions can inform public debate and policy regarding abortion and unwanted pregnancy. Demographic changes over the last two decades highlight the need for a reassessment of why women decide to have abortions. METHODS: In 2004, a structured survey was completed by 1,209 abortion patients at 11 large providers, and in-depth interviews were conducted with 38 women at four sites. Bivariate analyses examined differences in the reasons for abortion across subgroups, and multivariate logistic regression models assessed associations between respondent characteristics and reported reasons. RESULTS: The reasons most frequently cited were that having a child would interfere with a woman's education, work or ability to care for dependents (74%); that she could not afford a baby now (73%); and that she did not want to be a single mother or was having relationship problems (48%). Nearly four in 10 women said they had completed their childbearing, and almost one-third were not ready to have a child. Fewer than 1% said their parents' or partners' desire for them to have an abortion was the most important reason. Younger women often reported that they were unprepared for the transition to motherhood, while older women regularly cited their responsibility to dependents. CONCLUSIONS: The decision to have an abortion is typically motivated by multiple, diverse and interrelated reasons. The themes of responsibility to others and resource limitations, such as financial constraints and lack of partner support, recurred throughout the study.

Adolescents' reports of parental knowledge of adolescents' use of sexual health services and their reactions to mandated parental notification for prescription contraception.

CONTEXT: Legislation has been proposed that would mandate parental notification for adolescents younger than 18 years (minors) obtaining prescription contraception from federally funded family planning clinics. OBJECTIVE: To determine the extent to which parents are currently aware that their teenage daughters are accessing reproductive health services and how minors would react in the face of mandated parental involvement laws for prescription birth control. DESIGN, SETTING, AND PARTICIPANTS: A total of 1526 female adolescents younger than 18 years seeking reproductive health services at a national sample of 79 family planning clinics were surveyed between May 2003 and February 2004. MAIN OUTCOME MEASURES: Proportions of minor females who reported that a parent or guardian was aware that they were at the family planning clinic and, under conditions of mandated parental involvement, proportions of minors who would access prescription contraceptives at family planning clinics or engage in unsafe sex. RESULTS: Sixty percent of minors reported that a parent or guardian knew they were accessing sexual health services at the clinic. Fifty-nine percent of all adolescents would use the clinic for prescription contraception even if parental notification were mandated. This response was less common (29.5%) among adolescents whose parents were unaware of their clinic visits and more common (79%) among those whose parents were aware. Many adolescents gave more than 1 response to mandated parental involvement. Forty-six percent would use an over-the-counter method, and 18% would go to a private physician. Seven percent said that they would stop having sex as one response, but only 1% indicated this would be their only reaction. One in 5 adolescents would use no contraception or rely on withdrawal as one response to mandated notification. CONCLUSIONS: Most minor adolescent females seeking family planning services report that their parents are aware of their use of services. Most would continue to use clinic services if parental notification were mandated. However, mandated parental notification laws would likely increase risky or unsafe sexual behavior and, in turn, the incidence of adolescent pregnancy and sexually transmitted diseases.

Changes in Use of Long-Acting Reversible Contraceptive Methods Among U.S. Women, 2009-2012.

OBJECTIVE: To examine current levels, current correlates of, and changes in long-acting reversible contraceptive (LARC) use, including intrauterine devices and implants, among females aged 15-44 years using contraception between 2008-2010 and 2011-2013 with specific attention to associations between race, income, and age and their LARC use. METHODS: We analyzed data from two rounds of the National Survey of Family Growth, nationally representative samples of females aged 15-44 years, consisting of 6,428 females in 2008-2010 and 5,601 females in 2011-2013. We conducted simple and multivariable logistic regression analyses with adjustments for the sampling design to identify demographic characteristics predictive of LARC use and changes in these patterns between the two time periods. In this cross-sectional, descriptive study, our primary outcome of interest was current prevalence of LARC use among all contraceptive users at the time of the interview. RESULTS: The prevalence of LARC use among contracepting U.S. females increased from 8.5% in 2009 to 11.6% in 2012 (P<.01). The most significant increases occurred among Hispanic females (from 8.5% to 15.1%), those with private insurance (7.1-11.1%), those with fewer than two sexual partners in the previous year (9.2-12.4%), and those who were nulliparous (2.1-5.9%) (all P<.01). In multivariable analyses adjusting for key demographic characteristics, the strongest associations with LARC use in 2012 were parity (adjusted odds ratios [ORs] 4.3-5.5) and having a history of stopping non-LARC hormonal use (adjusted OR 1.9). Women aged 35-44 years (adjusted OR 0.3) were less likely to be LARC users than their counterparts (all P<.001). Poverty status was not associated with LARC use. There were no differences in discontinuation of LARC methods resulting from dissatisfaction between minority women and non-Hispanic white women. CONCLUSION: During the most recent time period surveyed, use of LARC methods, particularly intrauterine devices, increased almost uniformly across the population of users. LEVEL OF EVIDENCE: III.

Impact of the federal contraceptive coverage guarantee on out-of-pocket payments for contraceptives: 2014 update.

BACKGROUND: The Affordable Care Act requires most private health plans to cover contraceptive methods, services and counseling, without any out-of-pocket costs to patients; that requirement took effect for millions of Americans in January 2013. STUDY DESIGN: Data for this study come from a subset of the 1842 women aged 18-39 years who responded to all four waves of a national longitudinal survey. This analysis focuses on the 892 women who had private health insurance and who used a prescription contraceptive method during any of the four study periods. Women were asked about the amount they paid out of pocket in an average month for their method of choice. RESULTS: Between fall 2012 and spring 2014, the proportion of privately insured women paying zero dollars out of pocket for oral contraceptives increased substantially, from 15% to 67%. Similar changes occurred among privately insured women using injectable contraception, the vaginal ring and the intrauterine device. CONCLUSIONS: The implementation of the federal contraceptive coverage requirement appears to have had a notable impact on the out-of-pocket costs paid by privately insured women, and that impact has increased over time. IMPLICATIONS: This study measures the out-of-pocket costs for women with private insurance prior to the federal contraceptive coverage requirement and after it took effect; in doing so, it highlights areas of progress in eliminating these costs.