Pregnancies in the United States by Desire for Pregnancy: Estimates for 2009, 2011, 2013, and 2015.

We examine whether changes in U.S. pregnancy, birth, and abortion rates between 2009 and 2015 reflect underlying change in the incidence of pregnancies classified by retrospectively reported pregnancy desires: pregnancies reported as having occurred at about the right time, later than wanted, too soon, or not wanted at all, and those for which individuals expressed other feelings, including uncertainty, ambivalence, or indifference. We calculate the proportionate distributions of these pregnancies and rates among U.S. women aged 15-44, as well as change over time, overall and among age groups. Characterization of desires for a past pregnancy shifted in a number of ways between 2009 and 2015, and changes across age groups were not uniform. Rates of pregnancies reported as occurring later than wanted increased among older women, while rates of pregnancies reported as occurring too soon decreased among all women. These findings shed light on previous research documenting an increasing age at first birth, increasing rates of pregnancy and childbearing among the oldest age groups, and changes in patterns of contraceptive use, particularly among young women. Our analysis explores limitations and challenges of two major sources of data on pregnancies in the United States and their measures of retrospectively reported pregnancy desires.

Where Do Reproductive-Aged Women Want to Get Contraception?

Background: People's preferences regarding how they want to obtain contraception should be considered when building and refining high-quality contraceptive care programs, especially in light of recent shifts to incorporate more telehealth options into contraceptive care due to the coronavirus disease 2019 (COVID-19) pandemic. Methods: Our study is a cross-sectional analysis of population-representative surveys conducted between November 2019 and August 2020 among women aged 18-44 years in Arizona (N = 885), New Jersey (N = 952), and Wisconsin (N = 967). We use multivariable logistic regression to identify characteristics associated with each of five contraception source preference groups (in-person via health care provider, offsite with a provider via telemedicine, offsite without a provider via telehealth, at a pharmacy, or via innovative strategies), and we examine associations between contraceptive care experiences and perceptions and each preference group. Results: Across states, most respondents (73%) expressed preferences for obtaining contraception via more than one source. One quarter indicated a narrow preference for obtaining contraception in-person from a provider, 19% expressed interest in doing so offsite with a provider via telemedicine, 64% for doing so offsite without a provider via telehealth, 71% reported interest in pharmacy-based contraception, and 25% indicated interest in getting contraception through innovative strategies. Those who had experienced nonperson-centered contraceptive counseling reported higher levels of interest in telehealth and innovative sources, and those who expressed mistrust in the contraceptive care system had higher levels of preferring to obtain contraception offsite, via telemedicine, telehealth, and other innovative avenues. Conclusions: Policies that ensure access to a diversity of contraceptive sources, which acknowledge and address people's past experiences of contraceptive care, have the greatest likelihood of closing the gap between people's contraceptive access preferences and realities.

A Prospective Cohort Study of Changes in Access to Contraceptive Care and Use Two Years after Iowa Medicaid Coverage Restrictions at Abortion-Providing Facilities Went into Effect.

Inequities in access to contraception based on ability to pay can interfere with individuals' reproductive autonomy. This study examines the impact of a 2017 state-level policy in Iowa restricting Medicaid coverage at abortion-providing health care centers on patients' access to contraceptive care and subsequent contraceptive use. We draw on a unique panel dataset of individuals who originally sought care at a publicly supported family planning site in Iowa in 2018-2019 and then participated in subsequent follow-up surveys every 6 months for 2 years to examine an effect of access to care on contraceptive use. Among our final analytic sample of 368 individuals, our findings indicate that receipt of recent contraceptive care decreased over the study period; this coincided with patients shifting away from getting contraceptive care at sites potentially impacted by the 2017 Iowa Medicaid policy restriction while those getting this care at non-impacted sites remained relatively steady over the study period. At the same time, nonuse of contraception increased while use of a contraceptive method that carries cost, use of a provider-involved method, and satisfaction with one's method decreased. We find that, after controlling for patient characteristics, those who shifted toward receiving contraceptive care experienced increases in these three contraceptive outcomes. We interpret this as preliminary descriptive evidence demonstrating an impact of disruptions in access to contraceptive care on contraceptive outcomes. Supportive payment and funding strategies for contraception, rather than policies that impede or restrict access, are needed to enable people to realize full reproductive autonomy.

Financial Instability and Delays in Access to Sexual and Reproductive Health Care Due to COVID-19.

Objective: To identify prevalence of, and patient and clinic characteristics associated with, delays in access to sexual and reproductive health (SRH) care due to the COVID-19 pandemic across three states with varying COVID-19 context and state government response. Methods: We weighted data collected between May 2020 and May 2021 from monthly and biannual follow-up surveys of patients seeking family planning care at a publicly supported health center in Arizona (N = 538), Iowa (N = 341), and Wisconsin (N = 568), who reported on experiences 6-18 months before the survey. We conducted multivariable logistic regression analyses to identify characteristics associated with delays in accessing SRH care due to COVID-19, with specific attention to associations between patients' financial instability and experiencing delays. Results: Between May 2020 and May 2021, over half of respondents in Arizona (57%), 38% in Iowa, and 30% in Wisconsin indicated that they were either unable to access or delayed accessing SRH care or a contraceptive method due to the COVID-19 pandemic. In Arizona and Wisconsin, in multivariable models, respondents who had experienced financial instability due to being out of work, having fallen behind on key life payments, or because of a job reduction or loss due to COVID-19 had increased odds of experiencing COVID-19-related SRH care delays (Arizona adjusted odds ratio [aOR] = 2.6, p = 0.01 and Wisconsin aOR = 6.0, p < 0.001). Conclusions: Access to contraception was curtailed during the COVID-19 pandemic, especially for those who experienced employment and financial instability. Individuals' and clinics' ability to mitigate these effects were likely dependent on state context and response to the pandemic, among other factors.

Abortion Reporting in the United States: An Assessment of Three National Fertility Surveys.

Despite its frequency, abortion remains a highly sensitive, stigmatized, and difficult-to-measure behavior. We present estimates of abortion underreporting for three of the most commonly used national fertility surveys in the United States: the National Survey of Family Growth, the National Longitudinal Survey of Youth 1997, and the National Longitudinal Study of Adolescent to Adult Health. Numbers of abortions reported in each survey were compared with external abortion counts obtained from a census of all U.S. abortion providers, with adjustments for comparable respondent ages and periods of each data source. We examined the influence of survey design factors, including survey mode, sampling frame, and length of recall, on abortion underreporting. We used Monte Carlo simulations to estimate potential measurement biases in relationships between abortion and other variables. Underreporting of abortion in the United States compromises the ability to study abortion-and, consequently, almost any pregnancy-related experience-using national fertility surveys.

Use of Health Insurance Among Clients Seeking Contraceptive Services at Title X-Funded Facilities in 2016.

CONTEXT: As federal initiatives aim to fundamentally alter or dismantle the Affordable Care Act (ACA), evidence regarding the use of insurance among clients obtaining contraceptive care at Title X-funded facilities under ACA guidelines is essential to understanding what is at stake. METHODS: A nationally representative sample of 2,911 clients seeking contraceptive care at 43 Title X-funded sites in 2016 completed a survey assessing their characteristics and insurance coverage and use. Chi-square tests for independence with adjustments for the sampling design were conducted to determine differences in insurance coverage and use across demographic characteristics and facility types. RESULTS: Most clients (71%) had some form of public or private health insurance, and most of these (83%) planned to use it to pay for their services. Foreign-born clients were less likely than U.S.-born clients to have coverage (46% vs. 75%) and to use it (78% vs. 85%). Clients with private insurance were less likely than those with public insurance to plan to use their insurance (75% vs. 91%). More than one-quarter of clients not planning to use existing insurance for services indicated that the reason was that someone might find out. CONCLUSION: Coverage gaps persist among individuals seeking contraceptive care within the Title X network, despite evidence indicating increases in health insurance coverage among this population since implementation of the ACA. Future research should explore the impact of altering or eliminating the ACA both on the Title X provider network and on the individuals who rely on it.

Insurance-related Practices at Title X-funded Family Planning Centers under the Affordable Care Act: Survey and Interview Findings.

INTRODUCTION: Given the recent reforms in the United States health care system, including the passage and implementation of the Affordable Care Act, as well as anticipated upcoming changes to health care coverage, it is critical that publicly funded health care providers understand how to effectively work with their states' Medicaid programs and the private health insurance plans in their service areas to provide high-quality contraceptive care to the millions of women relying on services at these sites annually. METHODS: We collected survey data from a nationally representative sample of 535 clinics providing family planning services that received Title X funding and conducted semistructured interviews with 23 administrators at a subsample of surveyed clinics to explore provider-reported experiences working with health plans and to identify barriers to, and practices that lead to, adequate reimbursement for services provided. RESULTS: Providers report that knowledgeable staff are crucial to securing contracts with both public and private insurance plan issuers, and that the contracts they secure often include coverage restrictions on methods or services clinics offer their clients. Good staff relationships with issuers are key to obtaining adequate and consistent reimbursement for all covered services. CONCLUSIONS: Providers are trying to understand how insurance programs in their area knit together. Regardless of how U.S. health policies and delivery systems may change in the coming years, it is imperative that publicly funded family planning centers continue to work with health plans and maximize their third-party revenue to provide services to those in need.

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.

Unintended pregnancy in the United States: incidence and disparities, 2006.

BACKGROUND: The incidence of unintended pregnancy is among the most essential health status indicators in the field of reproductive health. One ongoing goal of the US Department of Health and Human Services is to reduce unintended pregnancy, but the national rate has not been estimated since 2001. STUDY DESIGN: We combined data on women's pregnancy intentions from the 2006-2008 and 2002 National Survey of Family Growth with a 2008 national survey of abortion patients and data on births from the National Center for Health Statistics, induced abortions from a national abortion provider census, miscarriages estimated from the National Survey of Family Growth and population data from the US Census Bureau. RESULTS: Nearly half (49%) of pregnancies were unintended in 2006, up slightly from 2001 (48%). The unintended pregnancy rate increased to 52 per 1000 women aged 15-44 years in 2006 from 50 in 2001. Disparities in unintended pregnancy rates among subgroups persisted and in some cases increased, and women who were 18-24 years old, poor or cohabiting had rates two to three times the national rate. The unintended pregnancy rate declined notably for teens 15-17 years old. The proportion of unintended pregnancies ending in abortion decreased from 47% in 2001 to 43% in 2006, and the unintended birth rate increased from 23 to 25 per 1000 women 15-44 years old. CONCLUSIONS: Since 2001, the United States has not made progress in reducing unintended pregnancy. Rates increased for nearly all groups and remain high overall. Efforts to help women and couples plan their pregnancies, such as increasing access to effective contraceptives, should focus on groups at greatest risk for unintended pregnancy, particularly poor and cohabiting women.

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.