Contraceptive Use --- United States and Territories, Behavioral
Risk Factor Surveillance System, 2002
Please note:
An erratum has been published for this article. To view
the erratum, please click here.
Diana M. Bensyl, PhD,1 A. Danielle Iuliano,
MPH,2 Marion Carter, PhD,3 John Santelli,
MD,4 Brenda Colley Gilbert, PhD1
1Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
2Graduate School of Public Health, University of Pittsburgh, Pennsylvania
3The BOTUSA Project, Global AIDS Program, CDC, Gaborone, Botswana
4Mailman School of Public Health, Columbia University, New York, New York
The material in this report originated in the National Center for Chronic Disease Prevention and Health Promotion, Janet L. Collins, MD, Director; and the Division
of Reproductive Health, John Lehnherr, Acting Director.
Corresponding author: Diana M. Bensyl, PhD, Office of Workforce and Career Development, 1600 Clifton Rd, MS E-92, Atlanta, GA 30333. Telephone:
404-498-6153; Fax: 404-498-6355; E-mail: dbensyl@cdc.gov.
Abstract
Problem: Contraceptive use is an important determinant of unintended pregnancy. In the United
States, approximately half of all pregnancies are unintended. Population-based information about contraceptive
use patterns is limited at the state level. Information about contraceptive use for states can be used to guide
the development of state programs and policies to decrease unintended pregnancy and the spread of sexually
transmitted infections. Information about contraceptive use for specific subpopulations can be used to further refine state
efforts to improve contraceptive use and subsequently decrease the occurrence of unintended pregnancy.
Reporting Period: Data were collected in 2002 for men and women.
Description of System: The Behavioral Risk Factor Surveillance System (BRFSS) is a
random-digit--dialed, telephone survey of the noninstitutionalized U.S. population aged
>18 years. All 50 states, the District
of Columbia, Guam, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands participated in BRFSS
in 2002. These data can be used to track state progress towards the national health objectives for 2010
for responsible sexual behavior. The 2002 BRFSS data represent the first time state data on contraceptive use in
all 50 states will be presented and examined by selected sociodemographic characteristics. The 2002 BRFSS
also, for the first time, provided an opportunity to examine state-level contraceptive use patterns among men.
Results: Variation across states and territories was observed for the majority of contraceptive methods
among the different demographics analyzed and among men and women. The percentage of men and women at
risk for pregnancy who said they or their partner was using birth control was high overall and ranged from
67% (Guam) to 88% (Idaho). Oral contraceptives (i.e., the pill), vasectomy, tubal ligation, and condoms were
the methods most frequently reported by both male and female respondents who said they or their partner
was using birth control. Among female respondents using birth control, the pill was the most common
method reported. Among men, vasectomy was the most commonly reported method. The prevalence of use for
the four most commonly reported methods (pills, vasectomy, tubal ligation, condoms) varied as much as
six-fold among states for vasectomy and three- to four-fold for condoms, pills, and tubal ligation.
Interpretation: The findings in this report document substantial differences among states
and sociodemographic groups within states in contraceptive method use.
Public Health Action: These data can help states identify populations with an unmet need for birth
control, barriers to birth control use, and gaps in the range of birth control methods offered by health-care
providers. An analysis of the prevalence of birth control use by state and selected population characteristics can
help states target contraceptive programs to best meet the needs of their population.
Introduction
In the United States, approximately 49% of all pregnancies and 30% of live births in 1994 were unintended,
either mistimed or unwanted, at the time of pregnancy
(1). Unintended pregnancies are associated with poor maternal-child
health outcomes and behaviors such as smoking and drinking during pregnancy, delayed prenatal care, and low birthweight
(2). As a result, the reduction of unintended pregnancies is one of the family planning objectives of the national health objectives
for 2010 (3). Specifically, the objective is to increase the proportion of pregnancies that are intended to 70%. Another objective
is to increase the proportion of females at risk for unintended pregnancy (and their partners) who use contraception to
100%.Consistent use of effective birth control methods is the primary strategy for preventing unintended pregnancies
among sexually active persons. Patterns of contraceptive use by state reflect the availability of publicly supported reproductive
health services, preferences of women and health-care providers, and willingness of insurers to cover specific methods.
Eliminating barriers to access and to effective use of contraception will help meet the health objectives for 2010.
This report summarizes data from the 2002 Behavioral Risk Factor Surveillance System (BRFSS) survey, the first survey
to provide population-based information for all states and territories about birth control use for the prevention of
pregnancy among both women and men of reproductive age. BRFSS is the only population-based data source that provides
basic information for comparing birth control use among states and for informing state-level policy and program development.
The National Survey of Family Growth provides more detailed estimates of birth control use and related reproductive health
issues on a national and regional level (4).
This report focuses on the prevalence of birth control use for those reporting the following five methods: the pill,
condoms, tubal ligation, vasectomy, and injectable contraceptives (e.g., Depo-Provera ["the shot"]). These methods account for
83%--93% of birth control use for men and 84%--95% of birth control use for women.
Methods
BRFSS comprises population-based telephone surveys administered annually in all 50 U.S. states and four territories
among men and women aged >18 years, to collect surveillance data about a range of health behaviors and risk factors; the survey
is administered in English and other languages where appropriate and feasible
(5). No data are reported where sample sizes
for demographic characteristics and method choice are <50. In 2002, the overall response rates for the states ranged
from 25% to 79% (median: 45%), and cooperation rates among eligible respondents who were reached ranged from 63% to 99%
(77%). All data are presented for each state by sex.
To facilitate comparison with later years of BRFSS data on birth control use, data on the use of individual birth
control methods are based on the first method mentioned by the respondent, and use of more than one method is not included in
this report. The prevalence of each method's use changes little when respondents were categorized by their most effective
method rather than the method they mentioned first. Approximately 14% of all respondents reported using more than one method.
Questionnaire
Respondents of reproductive age (i.e., women aged 18--44 years and men aged 18--59 years) were asked whether they
or their usual partner were doing anything to prevent pregnancy. Those who answered yes were asked what method they or
their usual partner was using. Those who answered that they were not doing anything to prevent pregnancy were asked to
specify the main reason for not doing so.
Survey Questions
"Are you or your [if female, insert husband/partner; if male, insert wife/partner] doing anything now to keep [if
female, insert `you'; insert `her' if male] from getting pregnant?"
"What are you or your [if female, insert husband/partner; if male, insert wife/partner] doing now to keep [if
female, insert `you'; if male, insert `her'] from getting pregnant?"
Females were asked, "What is your main reason for not doing anything to keep you from getting pregnant?" Males
were asked, "What is your main reason for not doing anything to keep your partner from getting pregnant?"
"Did you (female respondent) have a hysterectomy?"
"Are you (female respondent) currently pregnant?"
Data Coding
For this analysis, the focus was on the contraceptive practices of men and women of reproductive age considered to be
at-risk for pregnancy. To identify men and women who were at-risk for pregnancy, persons who reported low-risk behaviors
or biologic reasons that indicated they were not at risk for pregnancy were excluded from the analyses. The not at risk
group included persons who reported that they or their partner were pregnant, had a hysterectomy, were not sexually active, were
too old to become pregnant, or were the same sex. Because respondents could report methods under question two (i.e.,
method using to prevent pregnancy) or as a reason for not using a method under question three (i.e., reason for
nonuse=hysterectomy), new variables that reflected use of specific methods regardless of how they were reported were created. The created
variables were developed from the original birth-control questions and additional questions relating to hysterectomy and
current pregnancy. These created variables were generated to facilitate analysis of these variables because of the complexity of
the responses and the need to combine multiple variables to obtain the prevalence estimates. Response patterns in the
original birth-control questions were complicated and interrelated; therefore, it was important to examine the entire set of questions
to report method use correctly. Three variables were created: any use of birth control, first mentioned method type, and
reason for nonuse among men and women of reproductive age.
To identify users, data from questions 1, 2, and 3 were needed. For example, certain persons who responded that they
were not doing anything to prevent pregnancy subsequently indicated in the reason for not doing anything that they or
their partner had a tubal ligation or had a vasectomy. Others responded that they were doing something to prevent pregnancy,
then indicated in type of method that they did not have a partner or were not sexually active. These respondents were categorized
as not at risk for pregnancy and as nonusers of birth control.
To describe the reasons for nonuse of birth control, data from all five questions were used. Respondents who did not
use birth control because they said they were not sexually active were identified in the first three questions. Respondents who
did not use birth control because they said they had a same-sex partner were identified in questions 2 and 3. Respondents who
did not use birth control because they said that they or their partner was pregnant were identified in questions 3 and
5. Respondents who did not use birth control because they indicated that they or their partner had a hysterectomy
were identified in questions 3 and 4. Reasons for nonuse were self-reported and include self-assessments of the respondents'
fertility. For example, a respondent who reported that she did not use birth control because "they can not get pregnant" might
be physiologically sterile from previous treatment for cancer, or she might be fertile but have a false perception of her true risk
for pregnancy.
The 2002 BRFSS had 148,702 female respondents; 65,597 responded to the family-planning questions. Of these,
61,525 (94%) answered the first contraceptive use question, 1,741 (3%) didn't know or refused to respond, 1,416 (2%) were
excluded because they did not meet the reproductive age criteria, and 915 (1%) were improperly skipped/not asked the question.
The remaining 57,453 women with valid responses were then examined to determine their at risk for pregnancy status.
An additional 9,549 (14%) were excluded because they reported that they were not sexually active, 4,128 (5%) were
excluded because they reported having had a hysterectomy, 2,693 (5%) were excluded because they reported that they were
pregnant, 362 (1%) were excluded because they reported a same-sex partner, and 99 (1%) were excluded because they
believed themselves or their partners too old to become pregnant. After the exclusions, a total of 44,694 women respondents
were considered to be at-risk for pregnancy and included in the analyses.
The 2002 BRFSS had 99,262 male respondents; 74,764 responded to the family-planning questions. A total of
70,784 (93%) men answered the first contraceptive question, 2,852 (3%) didn't know or refused to respond, 523 (1%) did not
meet the age criteria, and 1,128 (3%) were improperly skipped/not asked. The same criterion that was used to define the
at-risk subgroup for women was used to define the at-risk subgroup for men. Of the 93% of men that responded to the
contraceptive questions, 14,717 (20%) were excluded because they reported that they were not sexually active, 2,478 (3%) were
excluded because they reported that their partner had a hysterectomy, 940 (1%) were excluded because they reported that their
partner was pregnant, 587 (1%) were excluded because they reported a same-sex partner, and 2,556 (3%) were excluded because
they believed themselves or their partners to be too old to get pregnant. After the exclusions, a total of 48,983 men were
considered to be at risk for pregnancy and included in the final analyses.
Prevalence data are presented by state for all reported methods used (Tables 1 and
2) and for nonuse as an aggregate for
men and women (Table 3). Data are also presented by selected respondent characteristics for each state and sex for
those respondents who are contraceptive users (Tables 4--57). Only the five most commonly reported methods are
included.
Selected respondent characteristics include age group (18--24, 25--34, 35--44, and 45--59 years), race/ethnicity (white,
black, Hispanic, Asian/Pacific Islander, American Indian/Alaska Native, and other), employment status (employed or
unemployed), marital status (married, separated/divorced/widowed, and single), education (less than high school, high school degree,
and more than high school), health insurance (insured or not insured), and children at home (yes or no).
Data Collection and Analysis
BRFSS data are collected monthly by each state and sent to CDC, which then prepares the data for analysis by
applying weights by using the probability of being selected and the census estimates for age, race/ethnicity, and sex for each
state. SUDAAN® (Survey Data Analysis) software was used for data analysis to account for the complex sampling design.
Relations in the data were identified by using 95% confidence intervals for the prevalence estimates.
Results
Total Prevalence and Prevalence of Nonuse by State
Women
The percentage of women at risk for pregnancy who said they or their partner were using some method of birth control
was high overall and ranged from 67% (Guam) to 88% (Idaho). The prevalence of birth control use exceeded 80% in 44 of
54 states (median prevalence: 84%). Among female respondents who said they or their partner were using birth control, the
pill was the most common method reported in 49 of 54 states. Approximately one third of female users in the majority of
areas reported using this method, although the estimated percentage ranged from 19% (Puerto Rico) to 42% (South
Dakota) (Table 1). Tubal ligation was also commonly reported by women and ranged from 11% (District of Columbia) to
46% (Puerto Rico); this method was the most common in four states. Condom and vasectomy were the methods next
most commonly reported by women. Among birth control users, condom use ranged from 8% (Kentucky) to 33% (District
of Columbia) and was the most common method in one territory (U.S. Virgin Islands). Vasectomy did not rank first in any
area and ranged from 2% (District of Columbia) to 23% (Idaho). Injectable birth control (e.g., Depo Provera) was most
frequently reported by women in North Carolina (8%) and least frequently in Tennessee (2%). Prevalence of the use of an
Intra-Uterine Device (IUD) ranged from 6% in Utah to <1% in Mississippi. Prevalence of the use of foam, jelly, or cream, diaphragms,
and implants did not exceed 2% for any state. The prevalence of the rhythm method was highest in Puerto Rico (10%) and
lowest in Kentucky (<1%). Prevalence of withdrawal ranged from 3% in Guam and zero in four states (Maine, New Mexico,
North Dakota, and Ohio). Use of other methods did not exceed 4%, and those who did not know or did not respond ranged
from 6% (Rhode Island) to <1% (Oklahoma).
Men
Among men, the prevalence of some method of birth control use ranged from 68% (New Jersey) to 86% (Idaho) (Tables
1 and 2). For men, prevalence of birth control exceeded 80% in 28 of 54 states.
Tubal ligation, vasectomy, the pill, and condoms were the methods most frequently reported by men who said they or
their partner was using birth control (Table 2). However, compared with women, the most common method reported by
men varied across states.
Vasectomy was most common in 17 states and was highest in Oregon (31%) and lowest in the U.S. Virgin Islands (5%).
Pill use had the highest prevalence in 15 states, ranging from 33% in South Dakota to 10% in Puerto Rico. Tubal ligation was
the most common method used in 12 states, ranging from 55% in Puerto Rico (55%) to 12% in the District of
Columbia. Condom use was highest in the U.S. Virgin Islands (51%) and lowest in Montana (11%) and was the most common
method in 10 states.
Injectable birth control was most frequently reported by men in Arizona (6%) and least frequently in the U.S. Virgin
Islands (<1%). Prevalence of the use of IUD ranged from 4% in New Mexico to <1% in Alabama. Prevalence of the use of foam,
jelly, or cream, diaphragms, and implants did not exceed 2% for any state. The prevalence of the rhythm method was highest
in
Puerto Rico (7%) and lowest in Nebraska (<1%). Prevalence of withdrawal ranged from 2% in Guam and zero in four
states (Arizona, Kentucky, Ohio, and Wisconsin). Use of other methods was highest in Alabama (7%). Hawaii had the
highest prevalence for those who did not know or did not respond (9%).
Among women and men at risk for pregnancy, the most common reason given for not using birth control was that they
or their partner wanted to get pregnant (33% and 23%, respectively) (Table 3). Others not using birth control were likely to
be at risk for unintended pregnancy. For example, 6% of women said they were not using birth control because they or
their partner did not want, or like, to do so (Table 3). Substantial percentages of both men (14%) and women (9%) reported
they were not using birth control because they did not think they or their partner could become pregnant. The proportion of
those who were physiologically infertile is unknown.
Data by Selected Characteristics
Women
Although the shot had the next highest prevalence of use following pills, tubal ligation, vasectomy, and condoms, it
was never the most prevalent method for any state. Therefore, prevalence data are not discussed in detail in the results.
In all but one state, birth control pill use was highest among those aged 18--24 years. Prevalence of pill use among
this group ranged from 72% (Kansas) to 39% (New Jersey). In New Jersey, persons aged 18--24 years reported condoms (44%)
as the most common method. Among those aged 25--34 years, the pill was also the most common method reported.
However, for certain areas, condoms (District of Columbia) or tubal ligation (Mississippi, South Carolina, West Virginia, Wyoming,
and Puerto Rico) were more commonly reported. Women aged 35--44 years reported tubal ligation or vasectomy as the
most common method, except in the District of Columbia, where condoms were the most commonly reported method.
As a result of small sample size in certain states for specific racial/ethnic populations, data are not reported for every
state. Data for white women were available for all states except Guam, Puerto Rico and U.S. Virgin Islands. White women
most commonly reported using the pill, except in Kentucky, Tennessee, and West Virginia, where tubal ligation was reported
more often. Prevalence of pill use ranged from 50% (District of Columbia) to 29% (New Mexico). Twenty-four states had
adequate sample size for black women; methods of contraception varied more for black women than white women. Tubal ligation
was the most commonly reported method (15 states), followed by condoms (five states) and the pill (four states). Hispanic
women in 16 states reported most commonly using tubal ligation (eight states), followed by the pill (seven) and condoms (one).
Only a few states had adequate sample size to examine other racial/ethnic populations: Asian/Pacific Islander (California,
Hawaii, New Jersey, and Guam), American Indian/Alaska Native (Alaska, Montana, and Oklahoma) and other (Hawaii).
In California, Hawaii, Guam, and Alaska, these groups most commonly reported pill use. Montana and Oklahoma
most commonly reported tubal ligation and New Jersey reported condom use.
Among employed women, the birth control pill was the most reported method; prevalence ranged from 48% (Guam)
to 21% (Puerto Rico). However, in Mississippi, New Mexico, South Carolina, West Virginia, and Puerto Rico, tubal ligation
was more commonly reported. In the District of Columbia, condoms were more commonly reported (39%). The
unemployed category in this survey included students, homemakers, retirees, and those who were disabled. For those
reporting unemployment, pill use was the most common method except in Alabama, Kentucky, Tennessee, Texas, West Virginia,
Guam, and Puerto Rico, where tubal ligation was most common. In Illinois, New Jersey, and the U.S. Virgin Islands, condoms
were most commonly reported. In Washington, vasectomy was the most common method reported by unemployed women.
The two most commonly reported methods used by married women for pregnancy prevention were the pill (24 states)
and tubal ligation (22). Vasectomy was the most common method reported for Idaho, Michigan, New Hampshire,
Oregon, Vermont, Washington, and Wisconsin. In Arkansas, pill use and tubal ligation had the same prevalence (30%). In all
states with adequate sample size, women who were separated, divorced, or widowed reported tubal ligation as the most
common method of birth control, except in Idaho, Kansas, New Jersey, and Wyoming, where pill use was more common. For
single women, pill use was the most common method except in Puerto Rico, where tubal ligation was more prevalent (32%),
and the U.S. Virgin Islands, where condom use was more prevalent (47%).
Certain states had sample sizes too small to include for those with less than a high school education, reflecting
higher educational attainment in those states. For 15 of the 18 areas with adequate sample size, tubal ligation was the most
common method reported by women with less than a high school education. Two states reported pill use and one state
reported
condoms as the most common method. For those with a high school education, the most common reported method was
tubal ligation (37 states) followed by the pill (13). Condoms had the highest prevalence for pregnancy prevention in the District
of Columbia (30%) and vasectomy had the highest prevalence in Washington (31%). For persons with more than a high
school education, the majority reported pill use as the most common pregnancy prevention method except in Puerto Rico,
where tubal ligation was most prevalent (40%) and the U.S. Virgin Islands, where condom use was the most prevalent
method (29%).
Women with health insurance in 51 areas reported using the pill as their method of birth control. In West Virginia,
Puerto Rico, and the U.S. Virgin Islands, tubal ligation had the highest prevalence among those with insurance. For those
without insurance, pill use was reported most often (24 states). However, tubal ligation (19 states) was also common. In
addition, condom use was most prevalent for five states.
For those with children at home, pill use was the most
prevalent method of birth control. For those without
children at home, tubal ligation was the most prevalent method (31 states), followed by pill use (17), vasectomy (four), and
condoms (two).
Men
Injectable birth control had the next highest prevalence of use after pills, tubal ligation, vasectomy, and condoms.
However, it was never the most prevalent method for any state.
Men reported use of contraceptives for themselves or their usual partner. Among men, condom use had the
highest prevalence among those aged 18--24 years, and use ranged from 64% in New Jersey to 21% in Oregon. Pill use was the
next most common method. Prevalence of pill use ranged from 67% (Nevada) to 18% (Mississippi). Among those aged
25--34 years, pills were the most common method reported (46
states).However, for certain areas, condoms (seven states) or
tubal ligation (Puerto Rico) were more commonly
reported.Men aged 35--44 years reported tubal ligation or vasectomy as the
most common method, except in the District of
Columbia, Illinois, and the U.S. Virgin Islands, where condoms were the
most commonly reported method and in Connecticut, where the pill was the most common method. For men aged 45--59
years, tubal ligation or vasectomy was reported most often except in the District of Coulmbia and the U.S. Virgin Islands,
where condoms were more commonly reported.
Race/ethnicity information was lacking for certain areas because of small sample sizes. White men most commonly
reported pill use (23 states), followed by vasectomy (20) and tubal ligation (seven). In New York and the U.S. Virgin Islands,
condoms were most commonly reported. Prevalence of pill use ranged from 45% (District of Columbia) to 17% (Wyoming).
Sample sizes were inadequate for Guam and Puerto Rico for white men. In 21 states, data were available for black men; condoms
were the most commonly reported method (14 states), followed by tubal ligation (six). One state (New Jersey) reported the pill
as the most common method. Hispanic men in 15 states reported most commonly using tubal ligation, followed by
condoms (five states), and the pill (two). Only a few states had adequate sample sizes for the other racial/ethnic populations:
Asian/Pacific Islander (California, Hawaii, New Jersey, and Guam); American Indian/Alaska Native (Alaska, Montana,
and Oklahoma); and other (Hawaii and Nevada). For Asian/Pacific Islanders, condom use was most commonly reported in
New Jersey and California, tubal ligation in Hawaii, and the pill in Guam. American Indians/Alaska Natives in Alaska
most commonly reported condoms, and those in Oklahoma and Montana most commonly reported tubal ligation. For
those reporting "other" as their race, in Hawaii, condom use was most common, and in Nevada, pill use was most common.
Employed men reported using the pill (19 states) more often than other methods. Vasectomy (17 states) and tubal
ligation (11) were the next most common methods. For unemployed men, condoms were the most common method in 23 states.
In 10 states, tubal ligation was the most prevalent method, and in 10 states, pill use was most prevalent. In Nevada,
the prevalence of pill use was the same as the prevalence for condom
use.In Alaska, Idaho, Montana, Oklahoma, Vermont,
and Washington, vasectomy was the most common method reported by unemployed men.
The two most commonly reported methods reported by married men for pregnancy prevention were tubal ligation
(27 states) and vasectomy (25). In Maryland, tubal ligation and vasectomy had the same prevalence (25%). In Illinois,
South Dakota, and Utah, pill use was most common. For men who were separated, divorced, or widowed, tubal ligation
and vasectomy were the most common method of birth control in 30 states. In 12 states, condoms were most common and in
six states, pill use was most common. For single men, condoms were the most common method in 35 states and pill use was
most common in 19 states.
As with women, many states had sample sizes too small to include for those with less than a high school education.
For states with adequate sample sizes for those with less than a high school education, 20 reported tubal ligation as the
most common method, four reported condoms (California, Michigan, North Carolina, and U.S. Virgin Islands), and one
reported pill use (Nevada). For those with a high school education, the most common reported method was also tubal ligation
(25 states), followed by condoms (12). For those with more than a high school education, pill use was the most
commonly reported method (31 states) followed by vasectomy (12), condoms (six), and tubal ligation (five).
The majority of men with health insurance reported using tubal ligation or vasectomy as their method of birth control
(31 states). Pill use was the most common method for 19 states, and condoms were most common in four states
(Delaware, District of Columbia, New York, and U.S. Virgin
Islands).For those without insurance, condoms were reported most
often (25 states), followed by pill use (17), and tubal ligation (nine). In Tennessee, the prevalence of pill use and tubal ligation
was the same (28%).
For those with children at home, pill use was the most prevalent method of birth control (33 states) followed by
condoms (13), and tubal ligation (seven). In Montana, vasectomy and pill use had the same prevalence (28%). In Wyoming,
vasectomy was the most common method.For those without children at home, tubal ligation was the most prevalent method (33
states),followed by vasectomy (18), and condoms (nine). Pill use was most prevalent in Nevada, Rhode Island, and South Dakota.
In Kansas, prevalence of pill use and vasectomy was the same (27%).
Discussion
Several factors influence whether a couple at risk for pregnancy uses birth control to prevent pregnancy, what method
they use, and how effectively they use it. These include whether they have access to affordable, high-quality reproductive
health services and methods, their beliefs about the effectiveness of various methods, their perceptions of pregnancy risk,
their fertility goals, their partner's preferences, and their provider's recommendations
(2). Differences among state and territory populations in these and other factors might account for differences in the prevalence of birth control use and in the types
of birth control methods used.
The findings in this report indicate substantial differences among states and sociodemographic groups within states
in contraceptive method use and raises questions about how reproductive health attitudes and services differ among
states, especially among those of similar demographic composition. Geographic variation might reflect the demographic
composition of specific states, the influence of state policies and programs, the prescribing preferences of health-care providers, and
other factors. For example, the prevalence of condom use in a state might be influenced by rates for human immunodeficiency
virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) within that state.
Previous studies indicate that negative attitudes toward contraception affect a woman's decision whether or not to use
(6--10). Concern about contraceptive methods, including problems with methods in the past and fear of side effects, are
also common reasons for nonuse among women aged
>18 years.In addition, women report perceived low risk and
unexpected/unwanted sex as reasons for contraceptive nonuse
(9,10).
Variation by age and other sociodemographic factors within states are similar to recent national data on contraceptive
use (e.g., older respondents are expected to report sterilization methods more often)
(5). Tubal ligation was higher for older women in every state and, among male respondents, vasectomy increased by age in every state, although tubal ligation
was sometimes reported more often by men aged 35--44 years than those aged 45--59 years.
The majority of surveillance of birth control use has been among women only. Data on men point to differences
between men and women in the reported prevalence with which certain methods are used, and in some states and territories, in
the reported percentage using birth control of any kind. The age difference in the two samples (age 18--44 years for women
and 18--59 years for men) accounts for part of these differences. Another explanation might be that BRFSS asks respondents
to report whether and what they or their partner is doing to prevent pregnancy. Because most available birth control methods
are female methods, women might be better able to report on birth control use and type than their male partners. Women
and men also might not tell their partner(s) whether they are using birth control and, if so, what kind(s).
Although use of contraceptives by those at risk for pregnancy was high overall, usage and method choice varied
substantially by state. In particular, the District of Columbia and the territories demonstrated unique characteristics from the
states. Condom use prevalence was much higher in the District of Columbia and the U.S. Virgin Islands for both men and
women
than use of other methods in the 50 states. This might be attributed to an increased prevalence of sexually
transmitted infections. The overall AIDS rate for the United States in 2003 was 167 per 100,000 population. However, the AIDS rate
was 1,833 for the District of Columbia and 345 for the U.S. Virgin Islands
(11). The high prevalence of condom use
might indicate that messages for protecting against infections are effective in increasing condom use, a lack of quality family
planning services, or limited accessibility to other methods. For example, funding sources for contraceptive programs vary by
state depending on local support for contraceptive activities, private foundation funding, and other resources. Within states,
groups might exist with a higher unmet need for birth control, increased barriers to contraceptive use, and gaps in the range
of methods offered by health-care providers
(12,13). The differences in contraceptive prevalence and method choice
underscore the existence of geographic variation and how programs must be tailored to the population to increase contraceptive use
and promote effective use.
Results for all methods demonstrate that certain effective (and some ineffective) methods are relatively rare. For example,
the diaphragm might have some value in preventing sexually transmitted infection and was once a relatively
common method. However, it has ceased to be a common birth control method. In addition, some of the methods reported
have limited effectiveness in preventing pregnancy (e.g., withdrawal and rhythm).
This report describes the percentage of respondents using various birth control methods but does not address
other important aspects of birth control use that are important for the evaluation of state and other family planning
programs. These include method efficacy, the consistency and correctness of method use, use of more than one method, satisfaction
with methods, use for stopping or spacing childbearing, and use for all reasons, including HIV/STD prevention.
Whenever possible, information on these aspects of birth control use should be considered when analyzing and interpreting the
reported results.
Limitations
BRFSS focuses on chronic disease risk behaviors and experiences and collects data for a limited range of
explanatory variables for analysis. The contraceptive module in 2002 does not include information on sexual and reproductive
health behaviors beyond those addressing method use and reasons for not using. For example, information on pregnancy
intentions was not explicitly collected in 2002. In addition, the information collected pertains only to contraceptive use to
prevent pregnancy; the questions do not address method use for preventing sexually transmitted diseases. This might explain the
lower prevalence observed for condoms. For example, the prevalence of condom use for the District of Columbia and the
U.S. Virgin Islands might reflect dual efforts of disease and pregnancy prevention.
Coding of the contraceptive variables to determine who was at risk for pregnancy presented some limitations. For
example, "not sexually active" might reflect different periods (i.e., not active during the preceding week to not active during
the preceding year). Respondents choosing this option might move in and out of the at-risk group. In addition, specifying
with precision the populations both at risk for pregnancy and at risk for unintended pregnancy is difficult with these data
because few questions could be dedicated to this topic in the core questionnaire. The National Survey of Family Growth provides
more detailed estimates of birth control use and related reproductive health issues on a national and regional level
(5).
BRFSS response rates are generally lower than comparable reproductive health surveys such as the National Survey of
Family Growth (5). However, response rates are similar to other national telephone surveys, and the reliability and validity of
BRFSS measures have been extensively examined
(14).
Conclusion
Comparable population-based information on contraceptive use for states can be used to guide the development of
state programs and policies to decrease unintended pregnancy and the spread of sexually transmitted diseases. States support
various family-planning programs through Medicaid programs. States also support Title X and other programs. Information
on contraceptive use for specific subpopulations can be used to further refine these state efforts. These data can help
states identify groups within a state who are experiencing a greater unmet need for birth control and who might have
increased barriers to birth control use. Low contraceptive prevalence within subgroups might suggest reduced access to
health-care services or other barriers to contraceptive use. Data also might indicate gaps in birth control methods offered by
health-care
providers. An analysis of the prevalence of birth control use by state and selected population characteristics and the analysis
of the prevalence of birth control methods by state can help states target contraceptive programs to best meet the needs of
their population. This information can be used to gain a better understanding of contraceptive use patterns within and across
states and among sociodemographic groups.
As the first population-based assessment of contraceptive practices in all 50 states, these results can serve as a baseline
for tracking future progress and changes in usage patterns as future rounds of BRFSS become available. Such tracking can
be important in evaluating state-supported family-planning programs, policies that expand insurance coverage for
contraceptive methods, and other programs to prevent unintended pregnancy. These data can be combined with data from public
and private sources such as family-planning programs and encounter data from health insurers to provide a more complete
picture of state efforts to prevent unintended pregnancy. To monitor the prevention of unintended pregnancy and efforts to
improve pregnancy planning, these data also can be combined with state data from the Pregnancy Risk Assessment Monitoring
System (15), which monitors births from unintended pregnancies and guides state program developments. Overall, these data
can help states identify populations with an unmet need for birth control, barriers to
birth-control use, and gaps in the range of birth control methods offered by health-care providers.
Acknowledgments
William Mosher, PhD, and Joyce Abma, PhD, National Center for Health Statistics, Division of Vital Statistics, CDC,
provided comments on the initial analysis and content of the report.
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