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Context: While differences in levels of contraceptive use across socioeconomic subgroups of women have narrowed greatly over time, large disparities remain in rates of unintended pregnancy. One reason is variations in the effectiveness with which women and their partners use contraceptive methods., Methods: Data on contraceptive use and accidental pregnancy from the 1988 and 1995 National Surveys of Family Growth were corrected for abortion underreporting and pooled for analysis. Use-failure rates were estimated for reversible methods during the first year, second year and first two years of use, for subgroups of women of various characteristics., Results: The average failure rate for all reversible methods, adjusted for abortion underreporting, declines from 13% to 8% from the first year of method use to the second year. First-year failure rates are highest among women using spermicides, withdrawal and periodic abstinence (on average, 23-28% in the first year), and lowest for women relying on long-acting methods and oral contraceptives (4-8%). On average, they exceed 10% for all users except women aged 30-44, married women and women in the highest poverty-status category. The chance of accidental pregnancy does not differ significantly between method users younger than 18 and those aged 18-19., Conclusion: Both user and method characteristics determine whether contraceptive users will be able to avoid unintended pregnancy. Family planning providers should help clients to identify methods that they are most likely to use successfully, and counsel them on how to be consistent users and to avoid behaviors that contribute to method failure.

Context: In every country, contraceptive behavior has important implications for fertility and the prevalence of sexually transmitted diseases (STDs). There has been relatively little attention to contraceptive practices in Canada, however, particularly how patterns of method use may have changed., Methods: Data on contraceptive use were collected from 5,315 women in the 1984 Canadian Fertility Survey, and from 3,220 women and 3,449 men in the 1995 General Social Survey., Results: Among Canadian women aged 15-49, current contraceptive use declined from 69% to 60% between 1984 and 1995. Pill use dropped from 19% to 17%, and IUD use declined from 6% to 3%. However, during the same period, condom use increased from 6% to 10%; tubal ligation declined from 24% to 17%, while vasectomy increased. In addition, the proportion of women sterilized for reasons other than contraception rose between 1984 and 1995. Men were less likely to rely on sterilization than were women (31 % vs. 40%). Men reported higher levels of condom use (22%), but lower levels of pill use among their partners (9%), than did women (10% and 17%, respectively)., Conclusions: Contraceptive behavior in Canada is unique: The decline in contraceptive use over the last decade has left Canada's overall contraceptive prevalence among the lowest in the industrialized world, and the rate of sterilization among the highest These changes in contraceptive behavior complicate efforts to plan for social and health needs, particularly policy decisions focusing on reducing infections with STDs.

Context: Trends in contraceptive use have implications for shifts in pregnancy rates and birthrates and can inform clinical practice of changes in needs for contraceptive methods and services., Methods: Information on current contraceptive use was collected from a representative sample of women of reproductive age in the 1995 National Survey of Family Growth (NSFG). This information is compared with similar data from 1982 and 1988 to examine trends in use, both overall and in social and demographic subgroups., Results: The proportion of U.S. women using a contraceptive method rose from 56% in 1982 to 60% in 1988 and 64% in 1995. As in 1982 and 1988, female sterilization, the pill and the male condom were the most widely used methods in 1995. Between 1988 and 1995, the proportion of users relying on the pill decreased from 31% to 27%, while condom use rose from 15% to 20%. The largest decreases in pill use and the largest increases in condom use occurred among never-married women and among black women younger than 25. Reliance on the IUD dropped sharply among Hispanic women, while use of the diaphragm fell among college-educated white women., Conclusions: The decline in pill and diaphragm use and the increase in reliance on condoms suggest that concerns about HIV and other sexually transmitted diseases are changing patterns of method use among unmarried women.

Despite long-standing public support for sex education in the schools, it has been difficult to show concrete effects of sex education on sexual and contraceptive behavior. Data from the 1988 National Survey of Family Growth indicate that exposure to a formal contraceptive education program increases the likelihood that a teenage woman will use a contraceptive method at first intercourse. According to the results of a multivariate analysis, the odds that a young woman will use any method and the odds that she will use a condom increase by about one-third following instruction about birth control; the effect on the likelihood of pill use, however, is nonsignificant. If contraceptive education occurs in the same year that a teenager becomes sexually active, the odds of any method use and of condom use are increased by 70-80%, and the odds of pill use are more than doubled. The results also suggest that with greater educational efforts, the proportion of teenagers who use condoms at first intercourse could increase from 52% to 59%, while the proportion using no method might decrease from 41% to 33%.

Approximately 2,614 agencies are providing family planning services in at least 5,460 clinics throughout the nation, a slight increase over the 2,462 agencies and 5,174 clinics that were estimated to be providing such services in 1983. Health departments operate an estimated 52% of clinic sites; Planned Parenthood affiliates, 15%; hospital, 6%; and other agencies, 27%. Although many agencies also offer noncontraceptive services, the large majority provide family planning services in separate clinic sessions devoted to that purpose. According to a 1992-1993 survey of a random sample of family planning agencies, Planned Parenthood affiliates provide contraceptive services for an average of 2,041 clients per clinic site, compared with 761 per health department clinic. The agencies report offering an average of 7.2 contraceptive methods at their clinics, with Planned Parenthood affiliates and hospitals offering the highest mean number, 9.2. The clinics provide an average of 8.3 tests and examinations for their medical contraceptive clients, with at least 98% providing a pelvic examination, blood pressure measurement, breast examination and Pap smear; 90% screen for anemia, and 70% screen for gonorrhea. While almost all of the agencies get some income from Medicaid (83%), only 15% receive more than 20% of their budget for contraceptive services from that source. The federal Title X program provides more than 20% of the budgets of 53% of agencies; state and local governments fund 40% of family planning agencies at that level; and client fees do the same for 32% of agencies. Some 92% of clinics with Title X funding provide the initial visit and a three-month supply of the pill without charge to clients with an income below the federal poverty level, compared with about 50% of clinics without Title X funding.

The proportion of U.S. women who used a contraceptive method at their first premarital intercourse rose from 47 percent in 1975-1979 to 65 percent in 1983-1988. Overall, and among non-Hispanic white women, this change resulted entirely from an increase in the use of condoms by their partners. The proportion of whites who used a condom at first premarital intercourse, for example, increased from 24 percent to 45 percent. Among blacks, condom use at first intercourse increased from 24 percent to 32 percent during that period, and pill use rose from 15 percent to 23 percent. Among all women, the method most often used at first intercourse during every period in the study was the condom, followed by the pill and withdrawal. The proportion of women using a method at first premarital intercourse varies strikingly according to individual characteristics. Among the various demographic subgroups, the proportion who use a method varies from 32 percent of Hispanic women to 68 percent of Jewish women. Whites are more likely to use a method than are blacks, and fundamentalist Prostestants are less likely to use a method than are other Protestants or Catholics. The proportion using a method is higher among women whose mothers completed high school than among those whose mothers did not. In addition, the proportion rises with age at first intercourse. Multiple logistic regression showed that the independent effects of Hispanic origin, Jewish or fundamentalist Protestant religious affiliation and the education of a woman's mother are large and significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Despite fluctuations in current use rates for oral contraceptives, ever-use of the pill has remained remarkably stable for all cohorts of U.S. women born since 1945. Approximately 80 percent of these women report having used the pill at some time. Average duration of use is about five years among cohorts who had access to the pill from their earliest reproductive years. Among women born before 1940, whites are more likely than blacks to have ever used the pill, but no racial difference is evident among women in later cohorts. Age at first use of the pill has declined with each succeeding five-year birth cohort. Black women are more likely than white women to have used oral contraceptives before age 18, but by age 25, about three-fourths of blacks and whites have used the pill. Among ever-users born before 1945, the majority began taking the pill after their first full-term pregnancy; this pattern is reversed among more recent cohorts.

At the beginning of the 1960s, the Netherlands was basically a conservative society, in which there was little public discussion of birth control or of any sex-related topic. Then, beginning in the 1960s, a series of revolutionary changes in attitudes transformed the Netherlands. The pill was introduced in 1964, and within four years, four out of 10 Dutch women between the ages of 21 and 34 had used it. In 1971, the pill and sterilization were both made available free of charge through the national health insurance plan. By 1974, three-quarters of currently married women 20-42 years of age had ever used the pill, and by 1981, more than 700,000 men and women of reproductive age had had voluntary sterilizations, so that approximately 20 percent of all Dutch couples of reproductive age were protected from pregnancy by sterilization. As might be expected, the wide use of effective contraceptive methods during the late 1960s and the 1970s produced an unprecedented fertility downturn in the Netherlands: The crude birthrate fell from about 20 births per 1,000 population in 1965 to 13 per 1,000 in 1975; the total fertility rate fell from 3.1 births per woman in 1960 to 1.7 in 1975. The birthrate and the abortion rate among teenagers both declined during the 1970s; since sexual activity among teenagers was far more common at the end of the decade than at the start of it, the decline suggests that teenagers used modern contraceptive methods, especially the pill, effectively. At present, contraceptives are widely available, usually at no cost, throughout the Netherlands.(ABSTRACT TRUNCATED AT 250 WORDS)

During the decade 1973-1982, use of oral contraceptives declined sharply among wives aged 15-44, although the total number of pill users did not decrease after 1979. This drop occurred in all groups of wives examined. At the same time, the prevalence of female contraceptive sterilization rose sharply; this increase occurred mainly among wives aged 35 and older and, of course, among all wives intending no more children. Among other subgroups of married women, the fall in pill use was complemented by a smaller rise in the use of barrier methods--the condom and diaphragm, in particular. The contraceptive status and method choices of never-married and previously married women differed sharply from those of wives as of 1982. Sexually active never-married women were less likely than married women to practice contraception and were more likely to choose the pill when they did. Previously married women were also less likely than wives to practice contraception but, when using a method, were more likely than either never-married or currently married users to depend on one of the more effective methods--sterilization, the pill or the IUD.

U.S. women have fewer birth control options than do women in other developed countries. Reliance on sterilization helps many couples make up for their lack of choices, but high rates of sterilization among relatively young women are a cause for concern, given the chance of later regret. Although pill use is very high among young women, it falls dramatically among those in their 30s and, often unnecessarily, is minimal among those over 35. The IUD is most appropriate for older women in mutually monogamous relationships who have completed their families, and its availability has been limited in recent years because of liability problems. Although barrier methods are widely used by women of all ages, they are less effective than the pill or IUD. It is fair to conclude that given U.S. women's sometimes long intervals of exposure to the risk of unintended pregnancy, too few safe and effective reversible contraceptives are available in the United States. The addition of an acceptable new method would certainly lead to a reduction in unintended pregnancies, but many potentially useful new methods will not be developed in this century unless the amount of money invested in contraceptive research and development is substantially increased.

In 1982, 69 percent of Puerto Rican women in union were practicing contraception. Forty-five percent relied on contraceptive sterilization (40 percent, female, and five percent, male), eight percent were using the pill, four percent each, the IUD and the condom, five percent relied on rhythm, and three percent were using other methods. Thus, sterilization is the dominant form of fertility regulation in Puerto Rico, and there is relatively little use of reversible methods for childspacing. Reliance on female sterilization peaks among women in union in the age-group 35-44 (54 percent), whereas pill use is highest among those aged 15-24 (approximately 23 percent). Overall, eight percent of all women aged 15-49 are at risk of unintended pregnancy because they are fecund, sexually active, not pregnant or seeking pregnancy and not using any kind of contraceptive method. However, among women in union, this risk ranges from nine percent among those aged 30-39 to 22 percent among women aged 15-19. Reliance on sterilization rather than reversible methods of contraception is strongly influenced by socio-demographic variables. Women with less than a high school education, the wives of blue-collar workers, women living outside of the major cities and those born in Puerto Rico depend upon sterilization more than do women with a college education, the wives of white-collar employees, women living in cities and those born outside of the country. These findings point to the need for improved availability of reversible family planning services, especially for young women, and those whose childbearing is incomplete.

As the number of Canadian women who have had induced abortions increases with each succeeding year, the number at risk--and the actual incidence--of repeat abortion also increases. Some researchers have argued that women who have more than one induced abortion are less well adjusted, others that they are less willing to use contraceptives, perhaps because of anxiety about sexuality. Still others have suggested that repeat abortion is unrelated to the psychology or attitudes of individual women, but rather is an inevitable result of imperfect contraceptives, imperfect contraceptive practice and the availability of legal abortion for the termination of unwanted pregnancies. A group of 580 women seeking abortions were interviewed at the Montreal General Hospital and given a number of psychological tests. About one in five of these women were having repeat abortions. The women having repeat abortions were older, less likely to be married and more tolerant of legal abortion than were women having their first abortions. They also had intercourse more frequently than the first-abortion patients. Women obtaining a repeat abortion were slightly more likely to have been using contraceptives at the time they became pregnant, but they did not differ from first-abortion patients in the types of methods that they used. On no other social or demographic characteristics, measures of psychological adjustment or attitudes about sexuality were there any important differences between the groups. A more complex statistical analysis reveals that the two most important factors differentiating first-abortion and repeat-abortion patients are age and coital frequency--both of which are variables that reflect added exposure to the risk of unintended pregnancy.(ABSTRACT TRUNCATED AT 250 WORDS)

The cost of contraception is one factor that affects the choice of a birth control method. An analysis of the first-year costs for the various methods, based on fees charged by private physicians and supplies purchased at drugstores, shows that the cost can be considerable and that there are large differences in cost between methods. Prescription contraceptives--the pill, IUD and diaphragm--are by far the most expensive of the reversible methods because they require medical supervision, but supplies alone are also more expensive for prescription methods than for nonprescription methods. First-year cost is highest for the pill-$172, compared with $160 for the diaphragm and $131 for the IUD. The mean of $154 for these three prescription methods is almost four times the mean first-year cost of $40 for condoms and foam. Sterilization necessitates the largest initial expenditure, and the cost of tubal ligation-$1,180-is almost five times the cost of vasectomy-$241. However, sterilization represents a one-time cost, while the other methods involve recurring expenses that may add up to more than the cost of sterilization over time. The methods that are associated with the lowest failure rates-sterilization, the pill and the IUD-are among the most expensive. To offset the costs of contraception, 4.6 million American women obtained low-cost care from subsidized family planning clinics in 1980.

Canada's first national fertility survey, carried out by telephone in 1984, found that 68 percent of all women aged 18-49-73 percent of currently married women, 69 percent of the previously married women and 57 percent of single women--are practicing contraception. Overall, the most widely used method of birth control in Canada is sterilization (male and female), which is relied on by almost 60 percent of all married users and 66 percent of previously married users. Among single women, the preferred method is the pill, chosen by seven out of 10 of such users. Among all women, the major determinant of method choice is age: The pill is overwhelmingly chosen by women under 25, and sterilization, by those 30 and over. While the IUD and the condom are used by roughly 10-14 percent of women in their 20s who practice contraception, these methods decline in importance with increasing age. Highly educated women are less likely than those with little education to elect sterilization, and more likely to rely on barrier methods. Differences in contraceptive prevalence and patterns of use between Catholics and Protestants have all but disappeared in Canada, but church attendance and country of birth appear to exert a modest influence on method choice. As might be anticipated, women whose family size is complete have considerably higher levels of contraceptive use than those who expect to have more children. The survey reveals no difference in contraceptive use between Quebec women and those in the rest of Canada, thus confirming both the accuracy of earlier Quebec studies showing extremely high levels of sterilization and the applicability of these findings to all other Canadian women.(ABSTRACT TRUNCATED AT 250 WORDS)

An analysis of data from the 1973 and 1976 National Surveys of Family Growth indicates that although marital disruption affects contraceptive practice, the patterns of contraceptive behavior among separated women who remain sexually active are very similar to those of women who remain married. Women about to separate rely less on barrier methods than do continuously married women, and this pattern persists after separation. It is likely that coitus-related methods are less frequently used because they require cooperation between the spouses. In addition, coitus-related methods are probably used less after separation because these methods are less effective, and unintended pregnancies are less desirable in the intermarital or postseparation period. As might be expected, both before and after separation, women who experience marital dissolution are less likely than the continuously married to be sexually active. The difference is greater after separation, but the major finding is the similarity of separated and continuously married women with respect to both coitus and contraceptive protection.

Data from a national sample of private physicians show that 86 percent of obstetrician-gynecologists, general practitioners and pediatricians are willing to prescribe contraceptive methods to adolescent women. However, only 59 percent are willing to serve unmarried minors without parental consent. The obstetrician-gynecologists are more likely to provide contraceptives than the other two specialists, and are likely to have fewer policy restrictions. Although pediatricians are the least willing to prescribe contraceptives (only 32 percent say they would do so for a 15-year-old patient), they are the most likely to refer such patients to other sources of care (61 percent of those who will not provide primary contraceptive care do so). The parental consent requirements that physicians set for contraceptive services are somewhat related to state policies. Seventy-five percent of physicians who provide contraceptive care for adolescents and who practice in states that clearly authorize minors to give their own consent for family planning services will serve unmarried minors on their own consent, compared with 62 percent in states without explicit minor consent laws. Physicians practicing in the Southwest are the most likely to provide contraceptive services to unmarried patients younger than 18, while those in the North are least likely to do so (88 and 67 percent, respectively). Ninety percent of private physicians who prescribe contraceptives for adolescent women will prescribe the pill, but smaller proportions will make the diaphragm or IUD available (61 and 23 percent, respectively). Among the physicians surveyed, the average fee that an adolescent would have to pay for an initial contraceptive visit, including laboratory tests, is $37. Of those who accept teenage contraceptive patients, only 53 percent will accept Medicaid reimbursement and only one percent indicate that they will instead provide free services to adolescents who cannot afford to pay the fee.

For more than four in 10 teenage women who first obtained a prescription contraceptive from a private doctor or family planning clinic prior to pregnancy, marriage or interview in 1979, that method was the first they had ever used. Whites were over two times more likely to have previously used a nonprescription method than were blacks. Blacks, on the other hand, were two times more likely than whites to have been virgins before first using a prescription method. Slightly more than half of all young women who used a prescription method first obtained it from a family planning clinic, and the remainder got it from a private physician. Blacks were much more likely to have gone to a clinic than were whites. Nine in 10 of those who obtained a prescription method chose the pill. Among blacks, there was no appreciable difference between those who got the method from a clinic and those whose source was a private doctor. Whites who obtained their method from a private doctor, however, were somewhat more likely to choose the pill than were those who got it from a clinic. Of all who had been sexually active before ever using a prescription method, about eight out of 10 whites, but only about five in 10 blacks, had previously used a nonprescription method. Overall, there was an interval of about one year between first intercourse and the time the young women first got a prescription method. Among whites, there was no difference in parental education or family stability between clinic and private physician patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Eighty-seven percent of black adolescent males attending an inner-city junior high school and senior high school in Baltimore report that they have had sexual intercourse. Eighty percent of the sexually experienced teenagers have used a contraceptive method--and 60 percent used one at last intercourse. Contraceptive practice is characterized by heavy reliance on male methods: Of those using a method at last intercourse, 41 percent relied on the condom; 15 percent, on withdrawal; and 14 percent, on a combination of male and female methods. Use of female methods alone (mostly the pill) accounted for 28 percent of contraceptive practice at last intercourse. Nine-tenths of the teenagers have heard of the pill and condom, but far smaller majorities have heard of the IUD and diaphragm (about three-fifths each). In general, this population regards the condom as comparable in effectiveness to the pill. More than two-fifths of those recognizing these methods believe the pill--and the condom--to be "very good" at preventing pregnancy, and one-fifth believe that about the IUD and diaphragm. Nearly four in 10 mistakenly believe that they need a parent's permission to attend a birth control clinic, while slightly more than half think they need permission to buy nonprescription contraceptives in a drugstore . Although nearly nine in 10 respondents recognize that boys share a responsibility for preventing pregnancy when they have sex, more than half are willing to tolerate unprotected coitus. Most wish to delay parenthood until their early 20s, but many of these adolescents appear to hold attitudes conducive to out-of- wedlock conception.(ABSTRACT TRUNCATED AT 250 WORDS)

A relatively new multivariate life-table technique has permitted the effect of socioeconomic characteristics on first-year contraceptive failure rates to be determined to a greater degree of precision than was possible in the past. This technique is employed in this article to determine the one-year rates of contraceptive discontinuation among currently married U.S. women, using data from the 1973 and 1976 National Surveys of Family Growth (NSFG). The results indicate that poor women, black women and younger women are all relatively more likely to stop using contraceptives for reasons other than method-switching or the desire to become pregnant, as are women who have not completed high school, Catholic women and those who have never had a birth. Of all methods, the IUD is associated with the lowest rate of discontinuation. Pill users over age 30 are more likely to stop using their method than are comparable women using the IUD, diaphragm or condom. Women relying on spermicides are generally most likely to cease using a method. Finally, the subgroups of women who are most likely to stop using a particular method also are generally the groups that are most likely to experience contraceptive failures, while those that are least likely to discontinue use are also least likely to fail. Two exceptions are women who rely on rhythm and those who use the pill. The former experience relatively high rates of failure but are relatively less likely to stop using the method, and the latter have relatively high rates of discontinuation despite a low rate of failure.

A program to provide teenage family planning clinic patients with special services designed to improve their ability to practice contraception effectively and avoid conception produced neither of these expected effects. Two types of special services were tested in nine clinics: one, to promote greater involvement of the teenager's family through special counseling sessions (family support); and the other, to provide more frequent contact between the teenager and clinic staff through telephone calls (periodic support). The services were provided in the six weeks following the first clinic visit. Only 36 percent of the girls who agreed to be in the family support group attended any counseling sessions, and only five percent of them came with a parent. Participation was greater in the periodic support group--84 percent of teenagers in the group received the follow-up phone calls. During the 15 months following the initial clinic visit, there were no significant differences in regularity of contraceptive use and pregnancy rates between the teenagers who received the special support services and those who received only the regular clinic services. About 40 percent of the special-service groups reported always using a contraceptive method during the study period, compared with 48 percent of controls; and about 40 percent of the former said they had rarely or never used a method, compared with 27 percent of the latter. The cumulative 15-month pregnancy rate was about 13 percent in both the special-service and the control groups.