Jennifer J. Frost

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.

CONTEXT: Women aged 18–29 have higher rates of unintended pregnancy than any other age‐group. Information is needed to understand what characteristics are associated with risky contraceptive use practices among this population and to develop new strategies for reducing these women's risk of unintended pregnancy. METHODS: Data related to unintended pregnancy risk were collected from a nationally representative sample of 1,800 unmarried women and men aged 18–29 surveyed by telephone in 2009. Among those at risk of unintended pregnancy, multiple logistic regression was used to assess associations between contraceptive knowledge, norms and attitudes and selected risky contraceptive behaviors. RESULTS: More than half of young men and a quarter of young women received low scores on contraceptive knowledge, and six in 10 underestimated the effectiveness of oral contraceptives. Among women, for each correct response on a contraceptive knowledge scale, the odds of expecting to have unprotected sex in the next three months decreased by 9%, of currently using a hormonal or long‐acting reversible method increased by 17%, and of using no method decreased by 17%. Fear of side effects, norms and attitudes that favor nonmarital pregnancy or undervalue the importance of contraception, pregnancy ambivalence and mistrust of government's role in promoting contraception were also associated with one or more risky contraceptive use behaviors. CONCLUSIONS: Programs to increase young adults’ knowledge about contraceptive methods and use are urgently needed. Given the demonstrated link between method knowledge and contraceptive behaviors, such programs may be useful in addressing risky behavior in this population.

I examined the 1995 and 2002 National Survey of Family Growth for patterns and trends in the use of sexual and reproductive health care services by US women according to type of provider. The percentage of women reporting receipt of contraceptive services rose between 1995 and 2002 (from 36% to 41%), and the level and mix of services received varied considerably according to type of provider. Women visiting publicly funded providers received a broader mix of services than did clients of private providers.

CONTEXT:  Pregnancies among contraceptive users account for nearly half of all unintended pregnancies and are almost entirely due to inconsistent or incorrect contraceptive use. Understanding what factors contribute to inconsistent contraceptive behavior can help efforts to reduce unintended pregnancy. METHODS:  In 2004, a nationally representative sample of women aged 18–44 using reversible contraceptive methods were surveyed to examine factors associated with contraceptive choice and with inconsistent use of the pill and condoms. Bivariate and multivariate analyses were used to examine the data. RESULTS:  Contraceptive choice was associated with a range of socioeconomic and partnership characteristics, and with pregnancy‐, method‐ and provider‐related experiences and attitudes; inconsistent pill or condom use was associated mainly with partnership, experiential and attitudinal factors. For example, not having a college education was negatively associated with pill use (odds ratio, 0.6) and positively associated with use of long‐acting methods (1.8–1.9). Women for whom avoiding pregnancy was only a little or not important had reduced odds of using the pill (0.4) and elevated odds of using other methods, such as withdrawal or periodic abstinence (4.4), and of using condoms inconsistently (2.6). Use of a method chosen mostly out of dislike of other methods was positively associated with condom use (4.0) and negatively associated with use of the pill or long‐acting methods (0.4 for each). Women who were not completely satisfied with their method were more likely than others to use their method inconsistently (1.6 for pill users and 1.9 for condom users). CONCLUSIONS:  Greater efforts are needed to provide women and their partners with a range of method options, to facilitate selection of methods that best suit their needs and circumstances, and to identify and assist users who are dissatisfied or are having difficulties using contraceptives effectively.

The average American woman--who wants two children--spends about three decades trying to avoid pregnancy and only a few years trying to become or being pregnant. Sexually active women who are not seeking pregnancy may nonetheless practice contraception poorly or may not use a method at all. A wide range of reasons explain this seeming contradiction, including personal feelings and beliefs; experiences with methods; fears about side effects; partner influences; cultural values and norms; and problems in the contraceptive care system. Helping women prevent unintended pregnancy requires a broad-based approach that addresses many of these issues. To identify possible strategies for improving contraceptive use in the United States, two nationally representative surveys investigated women's contraceptive experiences and clinicians' delivery of relevant care. One survey asked sexually active women aged 18-44 who were not seeking pregnancy about their contraceptive use patterns over a one-year period. We focused on adults because many studies have examined adolescents' behavior, and relatively little is known about the contraceptive difficulties experienced by adult women--who account for more than 90% of unintended pregnancies. The second survey asked public and private contraceptive service providers to describe their service delivery protocols and their perceptions of clients' difficulties with method use. Results of these surveys reveal a complex picture of women's motivation and of client-provider interactions that sometimes hinder effective contraceptive use. They also suggest a number of measures that providers can take to help clients improve their contraceptive practice--many of which would require only simple changes in counseling practices and clinical protocols--and that policymakers, researchers and advocates can take to help in this effort.

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.