The U.S. Preventive Services Task Force,1 Healthy People 2010,2 and the World Health Organization3 all recommend that more attention be focused on prevention of unintended pregnancy. Although unintended pregnancy has declined over the past decade, U.S. rates remain much higher than those in other developed countries—particularly among low-income women and teenagers.4,5 Analysis of these disparities can help guide the efforts of family physicians to prevent unintended pregnancy.
Unintended pregnancy is associated with health risks for mothers and children, including domestic violence, drug and alcohol use, delayed prenatal care, and low birth weight.5 Furthermore, a study comparing cohorts born before and after 1973 suggests that unwanted children are more likely to commit crimes as youths and young adults.6 These negative medical and psychosocial correlations underscore the importance of this issue—not just for women, but also for their families and society. Family physicians should put themselves at the forefront of the effort to make every child a wanted child.
The National Survey of Family Growth provides the most recent information on unintended pregnancy in the United States. Between 1987 and 1994, the percentage of unintended pregnancies decreased from 57 to 49 percent.5 About one half of unintended pregnancies end in abortion. The U.S. abortion rate fell by 17 percent from 1992 to 2000 (from 25.7 to 21.3 abortions per 1,000 women 15 to 44 years of age), reaching its lowest level since the 1970s.7
This decline varied considerably by subgroup. High-income women, college-educated women, and teenagers had the greatest decline. In contrast, the abortion rate increased in low-income women and low-income teenagers. Until the mid-1980s, U.S. abortion rates varied little across economic subgroups. After 1987, the rates started to diverge, and by 2000, the rate of abortion among low-income women was nearly double that in wealthy women. The ethnic differences in abortion rates diminish greatly when statistics control for income level.4 The economic disparities in U.S. abortion rates parallel the widening gap between rich and poor, and limitations in access to basic health care.
During the 1990s, women increased their use of contraception and became more likely to choose the most effective methods. In addition, the level of sexual activity among teenagers declined, their use of contraception at first episode of intercourse increased, and an increasing percentage of sexually active teenagers used more effective contraceptive methods. An Alan Guttmacher Institute group analyzed the decline in teenage pregnancy from 1988 to 1995, concluding that improved contraception among sexually active teenagers accounted for 75 percent of the decline and that increased abstinence explained the remaining 25 percent.8
Dedicated products for emergency post-coital contraception were released in the late 1990s. Despite the low level of public awareness of emergency contraception and significant barriers to its use (i.e., availability only by prescription, unreliable stocking in pharmacies), this option had a positive effect on the rate of unintended pregnancy. In 2000, emergency contraception prevented approximately 51,000 pregnancies.7
Little is known about the most effective ways to promote methods of preventing unintended pregnancy. Although community-based programs abound, evaluation has been sparse and outcomes often disappointing. Recent reviews of programs to prevent teenage pregnancy, including those with abstinence-based and multifaceted content, reveal mixed results. There is a similar knowledge gap about how physicians can optimize contraceptive counseling. However, one study suggests that providing women with comprehensive information about contraceptive options and using a patient-centered, respectful approach correlates with better adherence.9
Implications for Physicians
Focus preventive efforts on high-risk groups (especially teenagers and low-income women).
Regularly ask all patients of reproductive age (men and women) about contraception needs, even at office visits initiated for other reasons.
Use a patient-centered strategy to help patients choose a contraceptive method, acknowledging concerns that can interfere with adherence.
Inform patients about efficacy rates for different methods and recommend use of high-efficacy options.
Encourage patients to call or return to the office if they experience problems with the method chosen.
Prescribe emergency postcoital contraception when indicated. Employ advance prescription of emergency contraception as a backup, especially for patients using barrier methods.
Lowering the rate of unintended pregnancy requires an effective partnership between patients and physicians. Research on the most effective preventive strategies is essential for further progress in this area.