Matern Child Health J (2012) 16:S213–S221 DOI 10.1007/s10995-012-1097-5
Trends in Contraceptive Use among Florida Women: Implications for Policies and Programs Leticia E. Hernandez • William M. Sappenfield Cheryl Clark • Daniel Thompson
•
Published online: 11 September 2012 Ó Springer Science+Business Media, LLC 2012
Abstract Our study objective was to assess changes in effective contraceptive use among women at risk of unintended pregnancy in Florida in 2008 and 2009 compared with 2002 and 2004. Contraceptive use questions were available from Florida’s Behavioral Risk Factor Surveillance System (BRFSS) for both periods (n = 4,606). Log binomial regression was used with appropriate methods to account for complex sampling in the BRFSS. We examined the change in four effective contraceptive use groups: sterilization, long-acting reversible contraceptive (LARC), short-acting reversible contraceptive (SARC), and barrier methods. Prevalence ratios comparing the two time periods were adjusted by demographic characteristics, employment, insurance status, children at home, poverty level, health behaviors, and health status. No evidence of change was found in sterilization (Adjusted Prevalence Ratio APR = 0.96; 95 % CI: 0.84–1.10) or SARC (APR = 1.01; 95 % CI: 0.87–1.18). The overall use of LARC increased and use of barrier methods decreased significantly over the two periods (APR = 1.68; 95 % CI: 1.09–2.60 and APR = 0.77; 95 % CI: 0.61–0.98, respectively). Only two population groups experienced significant changes in prevalence in the four use groups over this period. NonHispanic White women increased their use of LARC (APR = 2.89; 95 % CI: 1.58–5.29) and women who have never been married decreased their use of barrier methods L. E. Hernandez (&) C. Clark D. Thompson Florida Department of Health, Division of Community Health Promotion, 4052 Bald Cypress Way, Bin A-13, Tallahassee, FL 32399, USA e-mail:
[email protected] W. M. Sappenfield College of Public Health, University of South Florida, Tampa, FL, USA
(APR = 0.51; 95 % CI: 0.33–0.77). Contraceptive use in Florida continues to be low overall with some shift towards more effective long-term methods. New efforts are needed to promote and increase family planning practices, which include the use of effective contraceptives. Keywords Contraceptive trends Sterilization LARC SARC Barrier Binomial regression
Introduction In 2002, Florida women aged 18–44 years at risk of unintended pregnancy, excluding women who were either planning to get pregnant or not currently at risk for getting pregnant, were found to have nearly the lowest prevalence of contraceptive use (79.4 %) compared with other United States and territories [1]. Another study found that during 2002 and 2004, effective contraceptive use among women was significantly lower in Florida than in seven other southeastern states. Effective contraceptives are defined as contraceptives assessed to be 80 % effective by the Food and Drug Administration (FDA) [2]. The prevalence of effective contraceptive use was 74 % for Florida and 82 % for the other states when including condom use, and 58 and 70 %, respectively, when not including condom use. Effective contraceptive use reduces the fertility rate by preventing unintended pregnancies among sexually active women [1]. Half of unintended pregnancies end in abortion, and women who continue their unintended pregnancies may have increased risk of detrimental prenatal behaviors, such as smoking and drinking, as well as negative health and social outcomes for both mothers and babies [3]. There is an association between unintended pregnancy and prematurity, low birth weight, and being
123
S214
small size for gestational age [4]. According to 2002 and 2004 Pregnancy Risk Assessment Monitoring System (PRAMS) data, 46.4 % of Florida mothers who had a live birth reported that their pregnancies were unintended, either not wanted at any time or wanted at a later time. The percentage of unintended live births in Florida increased slightly to 47.8 % in 2007 and 2008 [5]. Many U.S. states and other developed countries have reported a rising number of births and general fertility rates from 2000 until 2009. In 2009, there was stagnation or a slight decline in total births due to a close relationship between unemployment, postponement of reproductive plans, and fertility [6]. Fertility rates and contraceptive use have been found to be closely associated [1]. From 1999 to 2007, Florida’s fertility rate increased significantly from 62 per 1,000 women in 1999 to 67 per 1,000 women in 2007. In 2008–2009, the trend changed with a decrease almost to the same level of 10 years earlier to 64 per 1,000 women [7]. The recent economic recession is likely associated with the recent decline in fertility rates in Florida. Funded family planning services have helped women avoid unintended pregnancy by providing access to contraceptive services, supplies, and family planning information [8]. Nationally in 2006, publicly funded family planning services helped prevent 1.94 million unintended pregnancies, which likely would have resulted in an estimated 860,000 unintended births and 810,000 abortions [9]. State and federally funded family planning programs in Florida have experienced some decreases in funding, substantial increases in the cost of prescription contraceptive methods, and difficulties in hiring staff [10]. However, the need for family planning services has increased. Of note, Title X-funded family planning clinics in Florida reach only 18.3 % of the women in need of publicly funded family planning services [11]. In 2008, an estimated 930,100 (27 %) women aged 15–44 years in Florida were uninsured and therefore were potentially in need of publicly funded family planning clinics [12]. Also, according to Florida data from PRAMS in 2008, 40 % of recent mothers in Florida did not have health coverage one month prior to pregnancy. This percentage has been increasing over time since the year 2000 [13]. Given Florida’s low prevalence of contraceptive use, increase in unintended pregnancies, and change in general fertility rates, the Florida Department of Health (FDOH) wanted to investigate the relationships between these factors and contraceptive use practice patterns. The purpose of our study was to assess changes in effective contraceptive use among women at risk of unintended pregnancy in Florida in 2008 and 2009 compared with 2002 and 2004, by comparing the results of the contraceptive use questions from the Behavioral Risk Factor Surveillance System (BRFSS) over the two time periods.
123
Matern Child Health J (2012) 16:S213–S221
Methods Florida BRFSS data from the years 2002, 2004, 2008, and 2009 were used in this study. BRFSS is a collaborative effort between the Centers for Disease Control and Prevention and state health departments to annually administer population-based telephone surveys of men and women aged 18 years or older in all 50 U.S. states and four territories. The survey’s purpose is to collect data about a range of health behaviors, preventive health practices, and health care services. The data collected in the BRFSS are obtained through a complex sample design. Weighted BRFSS data represent results that have been adjusted for the probability of selection, for disproportionate selection of population subgroups relative to state’s population distributions, and non-response [14, 15]. During the study period, the overall response rate for Florida ranged from 42.6 % in 2004 to 51.5 % in 2009 [16, 17]. Our study sample was limited to women between 18 and 44 years of age who were at risk of an unintended pregnancy. Women were considered not to be at risk for an unintended pregnancy and were excluded if they were: (1) not sexually active, (2) had a same sex partner, (3) were pregnant, or (4) wanted to be pregnant at the time of the survey. Women with hysterectomies were also excluded, as hysterectomies usually are performed for medical reasons and are generally not used as a family planning method. All other women were considered at risk for an unintended pregnancy. The dependent variables used to ascertain whether contraceptive use patterns among Florida women changed over time were based on the following two BRFSS questions: (1) ‘‘Are you or your (husband/partner) doing anything now to keep (you) from getting pregnant?’’ and (2) ‘‘What are you or your (husband/partner) doing now to keep (you) from getting pregnant?’’ Women were asked to choose their primary contraceptive method. Those using contraceptive methods assessed to be 80 % effective by FDA were categorized as using an effective contraceptive method [18]. Four groups of effective primary contraceptive methods were defined and listed in descending order of effectiveness: (1) sterilization (male and female); (2) longacting reversible contraceptive methods (LARC) including intrauterine device (IUD) and implants; (3) short-acting reversible contraceptive methods (SARC) including injectables, pills, and the contraceptive patch; (4) and barrier methods including male and female condoms, and diaphragms-cervical rings-or caps. For the 2004 and 2008 surveys, diaphragms-cervical ring-or caps were included in one response category [19]. The outcome variable for each of these four contraceptive groups was determined through a comparison of: (1) women using sterilization compared with women who were not using sterilization, (2) women
Matern Child Health J (2012) 16:S213–S221
using LARC compared with women who were not using LARC, (3) women using SARC compared with women who were not using SARC, and (4) women using barrier methods compared with women who were not using barrier methods. The four outcome variables were each modeled separately. Each outcome compared women in one of the contraceptive groups to all other women at risk of unintended pregnancy, including those women in the other contraceptive groups. The time variable (main independent variable) was created by dividing the analytic time frame into two categories (1) women at risk of unintended pregnancy in 2002 or 2004 (first period) and (2) women at risk of unintended pregnancy in 2008 or 2009 (second period). Other factors previously found to be associated with the use of effective contraceptives were included in the analyses: age, race/ ethnicity, education, marital status, employment, insurance status, children at home, poverty level, current smoking status, access to a personal doctor, body mass index, and health status. To derive the poverty variable, the income level reported by each woman, together with the number of people who depended on this income, were converted into a percentage of the federal poverty level (FPL) using the U.S. Department of Health and Human Services poverty guidelines [20]. For each survey year included, the matching year’s poverty guidelines were used. All statistical analyses were performed using Stata 10.1 survey commands (STATA, StataCorp, College Station, TX, USA), which take into account the complex survey sampling design. All results were weighted except where specified. Statistical test results were determined as significant at p \ 0.05. Bivariate analyses and Chi square tests were conducted to describe the association between the four outcomes of interest—sterilization use, LARC, SARC, and barrier use and the independent variables previously listed, including the time variable. Binomial regression methods were used to calculate unadjusted and adjusted prevalence ratios for the four outcomes of interest and to estimate changes over time. Cross-product interactions were used to estimate differences in changes over time among different population groups. All significant interactions were identified using the Wald postestimation test in STATA. Correlation coefficients, tolerance, and variance inflation factors (VIF) were calculated to assess multicollinearity among the independent analysis variables.
Results Of 6,079 women aged 18–44 responding to the Florida BFRSS surveys, the study sample included 4,606 women at risk of unintended pregnancy. This represents 75.8 % of
S215
women surveyed overall, 70.8 % during the first time period (2002 and 2004) and 80.6 % during the second period (2008 and 2009). In total, there were 4,308 women at risk of unintended pregnancy with information about contraceptive use (Table 1). Weighted results estimated that 4,305,770 study women during the first period and 5,211,252 during the second period were at risk of unintended pregnancies (data not shown). This represents 72.0 and 81.3 %, respectively, of all women 18–44 years of age in Florida, reflecting a 13 % increase in the percentage of women at risk of unintended pregnancies between the two time periods (p \ 0.000). The percentage of women at risk of unintended pregnancy who reported either not using any contraception or not using an effective method increased slightly, but not significantly from the 2002 and 2004 time period to the 2008 and 2009 time period, 25.4 and 27.5 % respectively (p = 0.29). Table 2 presents the percentages of these women by type of effective contraceptive method used. The leading methods for both time periods were male and female sterilization (27.4 and 29.4 %), birth control pills (23.3 and 21.5 %), and male and female condoms (16.2 and 12.7 %), respectively. The percentage of women using effective contraception (sterilization, LARC, SARC, and barrier methods) by population characteristics and time period are shown in Table 3. Never-married women experienced a significant increase in use of sterilization over the study period. Significant increases in LARC methods were observed among women with the following characteristics: ages 18–24 years, ages 35–44 years, ever-married, non-Hispanic White, more than high school education, having health insurance, having a personal doctor, having 1 or 2 children, not being a current
Table 1 Number of surveyed women aged 18–44 years by unintended pregnancy risk status, over two time periods, Florida BRFSS Characteristics Total women surveyed 18–44 years Women not at risk of unintended pregnancy
2002 and 2004
2008 and 2009
3,002
3,077
877
596
Pregnant
(-) 115
(-) 90
Wanted to be pregnant
(-) 113
(-) 126
Had the same sex partner or did not have sex
(-) 440
(-) 225
Had a hysterectomy
(-) 209
(-) 155
2,125
2,481
(-) 109
(-) 189
2,016
2,292
Study women at risk of unintended pregnancy Women with missing information on contraceptive use Women at risk of unintended pregnancy with information on contraceptive use
123
S216
Matern Child Health J (2012) 16:S213–S221
Table 2 Weighted percentage of women aged 18–44 years using a primary effective contraceptive method by method type over two time periods, Florida BRFSS Contraceptive method
2002 and 2004
2008 and 2009
(%)
(%)
95 % confidence interval Lower limit
Sterilization Female
Upper limit
27.4
25.0
29.9
29.4
26.6
32.4
16.8
21.0
19.5
17.0
22.3
8.6
7.2
10.3
9.9
8.3
11.7
2.9
2.1
3.9
5.3*
4.1
6.7
2.3
1.6
3.3
4.5*
3.5
5.8
Male Intrauterine device Norplant Pills
Lower limit
18.8
Long-acting reversible methods
Short-acting reversible methods
Upper limit
95 % confidence interval
0.6
0.3
1.1
0.8
0.4
1.7
27.5
25.1
30.1
24.4
21.5
27.5
23.3
21.1
25.7
21.5
18.8
24.5
Injectable
3.3
2.5
4.4
2.3
1.5
3.5
Contraceptive patch
0.9
0.3
2.4
0.6
0.2
1.6
16.8
14.8
19.1
13.4*
11.1
16.2
16.2
14.2
18.5
12.7*
10.5
15.4
0.6
0.3
1.0
0.7
0.3
1.8
25.4 100.0
23.0
28.0
27.5 100.0
24.6
30.7
Barrier methods Condom (male and female) Diaphragm, cervical ring, or cap Non-effective methods or none Total
* p \ 0.05 comparing percentages by period
smoker, being obese, and reporting good health status. Over the study period, a significant decrease in SARC use was observed among non-Hispanic White women. Significant decreases between the two time periods in the percent of women using barrier contraceptives as a primary method was seen among women who were never-married, completed a high school education, were employed, and who were not currently smokers. In the full binomial regression models, no significant change was found for effective contraceptive use when comparing any effective method to a non-effective method (APR = 0.95; 95 % CI: 0.90–1.00) (data not shown). No evidence of significant changes were found in the use of sterilization (APR = 0.96; 95 % CI: 0.84–1.10) or SARC methods (APR = 1.01; 95 % CI: 0.87–1.18) over the two time periods. The use of LARC methods significantly increased and the use of barrier methods significantly decreased over the two time periods (APR = 1.68; 95 % CI: 1.09–2.60, and APR = 0.77; 95 % CI: 0.61–0.98, respectively). The comparison population used for each of these estimates is all other women at risk for unintended pregnancy who did not use the respective contraceptive group. All four models were adjusted for the same covariates (Table 4). When the effective reversible method groups, LARC and SARC, were combined into one category and compared with all other women at risk of unintended pregnancy using one binomial model, no significant
123
change was found over the two periods (APR = 1.07; 95 % CI: 0.94–1.23) (data not shown). To study whether changes over time varied by population subgroups, we examined four possible statistical interactions between population characteristics and time periods for each of the following outcome variables, sterilization, LARC, SARC, and barrier methods. Two significant interactions were found with time period: one each for LARC and barrier methods (See Figs. 1, 2). With LARC methods, a significant interaction was found with race/ethnicity (p = 0.006). Non-Hispanic White women reported a significant increased prevalence of use in the second period (APR 2.89; 95 % CI: 1.58–5.29). Non-Hispanic Black women (APR 1.79; 95 % CI: 0.37–8.50) and women of other races (APR 2.25; 95 % CI: 0.47–10.68) experienced non-significant increases in the second time period while Hispanic women (APR 0.75; 95 % CI: 0.33–1.65) experienced a non-significant decrease in the later period (Fig. 1). With barrier methods (Fig. 2), a significant time interaction was found with marital status (p = 0.01). The prevalence of barrier method use among women who were never married decreased in the second period when compared with the first period (APR 0.51; 95 % CI: 0.33–0.77). However, barrier methods used as a primary contraceptive method did not change significantly over time for women who had been married.
Matern Child Health J (2012) 16:S213–S221
S217
Table 3 Weighted percentage of women aged 18–44 years who used an effective method of contraceptive by demographic and health factors over two time periods, Florida BRFSS Demographic and health factors
Total
Sterilization (%)
Reversible (%) a
Barrier (%) SARC
b
2002 and 2004
2008 and 2009
24.4
16.8
13.4*
2002 and 2004
2008 and 2009
LARC
2002 and 2004
2008 and 2009
2002 and 2004
2008 and 2009
27.4
29.4
2.9
5.3*
27.5
Age (years) 18–24
5.7
7.5
1.1
6.1*
39.1
34.4
26.7
16.8
25–34
21.9
19.9
4.9
6.4
32.8
32.2
17.1
17.9
35–44
43.7
42.9
2.1
4.1*
16.8
15.5
11.3
9.0
Ever married
35.9
35.4
3.1
6.1*
23.2
21.1
12.8
12.3
Never-married
7.0
13.3*
2.3
2.7
38.0
33.1
26.5
16.6*
Non-hispanic white Non-hispanic black
30.1 27.5
33.1 25.2
2.0 0.9
5.9* 2.6
32.3 18.0
25.6* 20.6
13.6 22.7
11.4 19.2
Hispanic
22.9
25.9
7.0
5.1
22.5
25.5
18.3
13.7
Other
15.6
20.5
2.7
7.6
23.4
19.7
29.1
15.0 22.3
Marital status
Race/ethnicity
Education Less than high school
30.0
29.1
3.2
5.2
16.1
17.0
17.3
High school
31.2
36.5
2.3
4.8
24.5
20.0
15.7
More than high school
25.2
27.0
3.1
5.4*
30.8
26.7
17.3
14.0
Less than 100 FPL
35.0
36.0
2.7
6.0
19.2
20.0
18.3
12.1
100–\ 200 % FPL
29.8
29.3
3.7
6.3
25.7
23.2
16.1
13.8
200 % or more FPL
27.0
28.3
2.6
4.4
32.2
29.1
16.0
11.4
Employed
28.3
29.5
2.4
4.9
27.1
25.6
17.1
12.5*
Unemployed
25.4
29.1
4.0
6.1
28.5
21.8
16.4
15.5
Insurance (Has health insurance?) Yes 28.8
8.9*
Poverty level
Employment status
30.2
2.6
5.1*
29.3
25.5
16.0
13.2
23.2
26.9
3.5
6.0
22.0
20.7
18.7
13.6
Yes
29.4
29.9
2.2
4.9*
29.7
25.2
15.5
13.1
No
21.7
28.4
4.6
5.4
22.1
22.4
20.1
14.5
0 children
14.0
11.1
1.0
0.9
39.1
33.5
18.3
16.7
1–2 children
27.8
31.0
3.3
5.5*
25.7
24.0
17.4
13.4
3 ? Children
51.4
47.9
5.1
9.1
11.9
14.2
12.1
9.8
Yes
34.7
39.5
1.5
2.7
24.4
15.5
12.8
14.1
No
25.6
27.8
3.2
5.7*
28.3
25.8
17.8
13.3*
Not overweight or obese
23.8
28.3
3.5
5.5
31.5
27.4
16.1
12.4
Overweight (25–29.9 kg/m2)
32.7
29.2
2.3
4.9
23.4
24.9
18.3
14.4
Obese (C30 kg/m2)
32.5
31.8
2.0
6.5*
22.2
16.4
16.5
16.0
26.7
28.5
2.9
5.3*
28.1
24.2
16.9
13.5
No Access to a personal doctor
Number of children at home
Current smoker
Body mass index
Health status Good
123
S218
Matern Child Health J (2012) 16:S213–S221
Table 3 continued Demographic and health factors
Not good
Sterilization (%)
Reversible (%)
Barrier (%)
a
SARC
b
2002 and 2004
2008 and 2009
LARC
2002 and 2004
2008 and 2009
2002 and 2004
2008 and 2009
31.8
37.0
2.6
5.0
23.2
26.3
2002 and 2004
2008 and 2009
16.5
13.0
* p \ 0.05 a
Long-acting reversible contraceptive
b
Short-acting reversible contraceptive
Table 4 Crude prevalence ratios (CPR) and adjusted prevalence ratios (APR) for change in effective contraceptive use over two time periods, Florida BRFSS
Contraceptive method
CPR
95 % confidence interval Lower limit
APR
Upper limit
95 % confidence interval Lower limit
Upper limit
0.84
1.10
1.09
2.60
Sterilization 2002 and 2004
Ref.
2008 and 2009
1.07
Ref. 0.94
1.23
0.96
1.23
2.72
1.68*
LARC
Adjusted for age, race/ethnicity, education, marital status, health status, personal-doctor, number of children at home, current smoker, poverty level, employment, insurance, and body mass index (BMI) * p \ 0.05
2002 and 2004
Ref.
2008 and 2009
1.83*
SARC 2002 and 2004
Ref.
2008 and 2009
0.88
0.76
1.03
1.01
Ref. 0.87
1.18
Ref. 0.80
0.64
1.00
Ref. 0.77 *
0.61
0.98
Barrier 2002 and 2004 2008 and 2009
Discussion This analysis found no significant change in overall effective contraceptive use occurred in 2008 and 2009 compared with 2002 and 2004. Although the overall use of effective contraceptive use did not change, it is important to know the pattern of how women are choosing particular effective methods. The percentage of women using LARC as a primary contraceptive method in Florida increased while the percentage using barrier methods decreased over time. The increase in the prevalence of women using LARC during the second period may be partially influenced by stressful economic conditions. A 2009 Alan Guttmacher Institute study reported that due to the economic recession, 12 % of women who previously were not using long-term reversible methods were thinking about switching to a long-term reversible method [21]. The costs for LARCs, particularly IUDs, are high compared to other types of contraceptive methods. However, an economic analysis by the National Collaborating Centre for Women’s and Children’s Health in 2005 showed LARC methods were more cost effective in terms of total costs and pregnancies per 1,000 women than SARCs and condoms [22].
123
Ref.
Another possible reason for the increased prevalence in the use of LARC methods is that providers have been more likely to recommend IUD or implants when providing family planning counseling in recent years. A study of attitudes about the IUD found that in the United States providers are more positive about recommending LARCs as the harmful experiences with the Dalkon Shield become more distant with time. This may also be true in Florida. Also, the same study alluded to the possibility that IUDs and implants would be a welcome choice for many women, particularly for those with adverse effects when using SARCs [23]. In 2010, the U.S. medical eligibility criteria for contraceptive use (MEC), adapted from the World Health Organization, also states that LARCs may be the best choice for women with high health risk situations [24]. Additionally, a 2000 study of women requesting information on sterilization reversal demonstrated the importance of providers who counsel women seeking sterilization also discuss other highly effective reversible methods to avoid post-sterilization regrets [25]. Provider counseling is especially relevant for never-married women in Florida, since our analysis shows their use of sterilization increased between the two time periods (Table 3).
Matern Child Health J (2012) 16:S213–S221
Non-Hispanic Black (APR= 1.8; 95% CI: 0.4-8.5)
2.5 3.5 4.5 1.5
Hispanic (APR= 0.8; 95% CI: 0.3-1.7) Non-Hispanic White (APR= 2.9; 95% CI: 1.6-5.3)
1.0
Adjusted Prevalence Ratio
Other (APR = 2.3; 95% CI: 0.5-10.7)
.5
Fig. 1 Stratum-specific adjusted prevalence ratios (APR) for the change in LARC method use in 2008 and 2009 compared with 2002 and 2004, among women in different race/ ethnicity groups. Florida BRFSS. Adjusted for age, race/ ethnicity, education, marital status, health status, personaldoctor, number of children at home, current smoker, poverty level, employment, insurance, and body mass index (BMI)
S219
3.5 4.5 2.5 1.0
1.5
Ever Married (APR= 0.95; 95% CI: 0.7-1.3)
Never Married (APR= 0.5; 95% CI: 0.3-0.8)
.5
Adjusted Prevalence Ratio
Race/ethnicity
Marital Status
Fig. 2 Stratum-specific adjusted prevalence ratios (APR) for the change in barrier method use in 2008 and 2009 compared with 2002 and 2004, among ever-married women and never-married women. Florida BRFSS. Adjusted for age, race/ethnicity, education, marital
status, health status, personal-doctor, number of children at home, current smoker, poverty level, employment, insurance, and body mass index (BMI)
In 2002, U.S. Hispanic women were found to be using IUDs at three times the rate of U.S. non-Hispanic White women [23]. Hispanic women in Florida showed a similar pattern as U.S. Hispanic women in this time period as LARC was predominantly composed of IUD use. In Florida, for every non-Hispanic White woman using LARC in 2002 and 2004, 3.5 Hispanic women were using LARC. However, the prevalence of LARC use among Hispanic women reversed in 2008 and 2009. For every Hispanic woman using LARC in 2008 and 2009, 1.2 non-Hispanic White women used LARCs (Table 3). This result is evident in our study in the interaction between time period and race/ethnicity. Use of LARC among Hispanic women in Florida decreases (though non-significant) in 2008 and 2009 compared with 2002 and 2004. This was in contrast to a significant increase in LARC use for non-Hispanic White women. More research may be needed to understand the differences in LARC use among Hispanic women and nonHispanic White women over time. The decreased use of barrier contraceptives as a primary method over time raises many questions. For instance, what other family planning methods are being used by
women who stop using barrier contraceptives and are women switching to more effective or less effective contraceptive methods. The aforementioned 2009 Guttmacher study states that the economic recession was influencing more women, especially those who did not want more children, to think about sterilization (i.e., tubal ligation or a male partner undergoing vasectomy) [21]. In Florida, this may be true for never-married women who reported an increase in sterilization (Table 3). The Guttmacher study also suggested that some women stopped using birth control pills to save money [21]. In Florida, a reduction in the use of birth control pills occurred, as shown in Table 2. Although comparable Florida abortion data are not available, St. Petersburg and Sarasota Planned Parenthood, two local non-profit organizations in Florida that provide reproductive health services, observed an increase of 14 % in the number of abortions during the first 2 months of 2009 when compared with the same months the year before [26]. Our study shows that never-married women in Florida were less likely to use barrier methods in 2008 and 2009 than in 2002 and 2004. This decrease in barrier method use
123
S220
is not countered by a significant increase in other types of effective contraceptives when adjusted for covariates. Of note, Florida’s general fertility rate had been increasing from 1999 to 2007, and the percent of unintended births also increased from 2002 and 2004 to 2007 and 2008 [5]. In 2009, the general fertility rate decreased to almost the same level as it was 10 years earlier in 1999 [9]. This suggests the recession may also be affecting Florida’s fertility rates. Of importance, no significant concurrent increase in overall effective contraceptive use was identified. A significant increase in LARC use was found, but disappeared when LARC and SARC were combined into one category of effective reversible contraceptives. This suggests the decrease in the fertility rate may be related to an increase in LARC use and/or better compliance with existing methods. An alternate possibility is an increase in the use of abortions. This cannot be assessed accurately using Florida’s current abortion reporting system.
Limitations This study has several limitations. First, data on behaviors such as effective contraceptive use are self-reported and may not be fully accurate or complete. Second, this study examines only primary contraceptive methods at the time of the survey and does not examine the use of multiple methods or the change in methods by the same women over time. Further, the data used for this study do not permit us to assess how accurately and consistently a woman is using the reported method. Third, the response rates for the BRFSS in Florida were low for the 2002 and 2004 surveys (43.5 %) and for the 2008 and 2009 surveys (50.4 %). A study has suggested, however, that low response rates for random-digit dial household studies may not be problematic [27].
Implications The prevalence of using effective contraceptive methods in Florida was low over the two study periods examined. After adjusting for covariates, the prevalence of LARC use increased significantly while the prevalence of barrier method use decreased significantly over the two time periods. These changes, however, do not reflect simple overall shift from use of barrier methods to LARC. Instead, we observed different patterns of change in contraceptive method use among some subpopulations. For example, the increase in LARC use was highest for non-Hispanic White women and the decrease in barrier method use was largest among never-married women. In addition to variation in contraceptive method use, PRAMS data indicate that
123
Matern Child Health J (2012) 16:S213–S221
Florida’s high prevalence of unintended live births persists. Hence, new initiatives and resources are needed to promote, and thereby increase, the use of effective contraceptives in Florida. Acknowledgments The authors thank Dr. Deb Rosenberg and Dr. Kristin Rankin for their direction and analytical support during the coordination of the CDC-UIC ‘‘Survey Analysis Course’’ and Dr. Erin Sauber-Schatz, Dr. Ghasi Phillips, Dr. Lauren Zapata, Angel Watson, and Marie Bailey for their analytical contributions to this paper. The 2002, 2004, 2008, and 2009 surveys were conducted through CDCBRFSS grant support number U58DP001961-01.
References 1. Centers for Disease Control and Prevention. (2005). Contraceptive use-united states and territories, Behavioral Risk Factor Surveillance System, 2002. MMWR, 54 SS-06. 2. Zapata, L., Sappenfield, W., Curtis, K., Goodman, D., Morrow, B., Marchbanks, P., et al. (2010). High contraceptive non-use among women at-risk of unintended pregnancy in Florida. Unpublished manuscript. 3. Finer, L., & Henshaw, S. (2006). Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health, 38(2), 90–96. 4. Committee on Unintended Pregnancy. (1995). The best intentions: unintended pregnancy and the well-being of children and families. In Institute of Medicine. National Academy of Sciences. Washington, DC: National Academy Press. 5. Centers for Disease Control and Prevention. (2011). PRAMS ponder. http://www2.cdc.gov/prams/. Accessed March 21, 2011. 6. Sobotka, T., Skirbekk, V., & Philipov, D. (2010). Economic recession and fertility in the developed world. Vienna Institute of Demography. http://www.iiasa.ac.at/Research/POP/pub/Skirbekk/ Research%20Note%202009_Economic%20recession%20and% 20fertility_10Feb2010.pdf. Accessed April 5, 2011. 7. Florida Department of Health, CHARTS. (2010). http:// www.floridacharts.com/charts/chart.aspx. Accessed December 2, 2010. 8. Department of Health and Human Services. (2011). Family planning. Retrieved from http://www.hhs.gov/opa/familyplanning/ index.html. Accessed April 4, 2011. 9. Guttmacher Institute. (2011). An overview of contraception in the United States. http://www.guttmacher.org/media/presskits/2009/ 11/18/contraceptionoverview.html. Accessed April 4, 2011. 10. Florida Department of Health. (2011). Decreasing number of clients served in Florida title X family planning clinics 2009. In Family Planning Annual Report FPAR No 0402. 11. University of North Carolina. (2010). Region IV network for data management and utilization. The RNDMU project 26 Years. In Consensus in Region IV: Women and Infant Health Indicators for Planning and Assessment. http://www.shepscenter.unc.edu/data/ RNDMU/Databook2010.pdf. Accessed April 7, 2011. 12. Guttmacher Institute. (2009). A real-time look at the impact of the recession on publicly funded family planning centers. http:// www.guttmacher.org/pubs/RecessionFPC.pdf. Accessed July 15, 2010. 13. Womack, L., & Sappenfield, W. (2010). Preconception health: An issue for every women of childbearing age in florida. In Florida Department of Health. www.everywomanflorida.com/ Pages/Healthcare_Providers/Preconception_Health_Indicator_ Report.aspx. Accessed March 21, 2011.
Matern Child Health J (2012) 16:S213–S221 14. Centers for Disease Control and Prevention. (2010). Behavioral Risk Factor Surveillance System. http://www.cdc.gov/brfss/ about.htm. Accessed July 16, 2010. 15. Centers for Disease Control and Prevention. (2011). Comparability of data: BRFSS 2002. www.cdc.gov/brfss/technical_ infodata/surveydata/2002/compare_02.rtf. Accessed February 7, 2011. 16. Florida Department of Health. (2011). Sample size and response rate, Florida BRFSS. http://www.doh.state.fl.us/disease_ctrl/epi/ brfss/sample_size_and_rate.htm. Accessed May 1, 2011. 17. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. (2009) Summary data quality report. ftp://ftp.cdc.gov/pub/Data/Brfss/2009_Summary_Data_Quality_ Report.pdf. Accessed May 1, 2011. 18. Food and Drug Administration FDA. (2010). Birth control guide. http://www.fda.gov/downloads/ForConsumers/ByAudience/ ForWomen/FreePublications/UCM132770.pdf. Accessed April 30, 2010. 19. Contraceptive Technology. (2010). Contraceptive options poster. http://www.managingcontraception.com/shopping/product.php? productid=16163. Accessed January 2, 2011. 20. U.S. Department of Health and Human Services. (2010). Health and Human Services Poverty Guidelines. http://aspe.hhs.gov/ poverty/09poverty.shtml. Accessed July 16, 2010.
S221 21. Guttmacher Institute. (2009). A real-time look at the impact of the recession on women’s family planning and pregnancy decisions. http://www.guttmacher.org/pubs/RecessionFP.pdf. Accessed July 15, 2010. 22. National Institute for Health and Clinical Excellence. (2005). Long-acting reversible contraception. http://www.nice.org.uk/ CG030. Accessed February 25, 2011. 23. Sonfield, A. (2007). Popularity disparity: Attitudes about the IUD in Europe and the United States. Policy Review, 10(4), 19–24. 24. Centers for Disease Control and Prevention. Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion. (2010). U.S. Medical eligibility criteria for contraceptive use, 2010. Adapted from the World Health Organization medical eligibility criteria for contraceptive use (4th ed). MMWR (Vol. 59). 25. Schmidt, J., Hillis, S., Marchbanks, P., et al. (2000). Requesting information about and obtaining reversal after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Contraception, 74(5), 892–898. 26. Tampa Bay News. (2010). http://www.ippf.org/en/News/Intl? news/US?Recession?affects?family?planning?with?abor tions?and?vasectomies?up.htm. Accessed October 15, 2010. 27. Groves, M. (2006). Nonresponse rates and nonresponse bias in household surveys. Public Opinion Quaterly, 70(5), 646–675.
123
