Contraception: To use or not to use isn't the only question for women

Half at risk aren't fully protected from unintended pregnancy

Your last patient has left the exam room with a prescription for birth control in her hand. You counseled on proper use and covered the expected side effects. Is she now protected against unintended pregnancy?

New research indicates that each year, half of women at risk are not fully protected from an unplanned pregnancy.1 The research, published by the Guttmacher Institute of New York City, shows that 8% use no contraception at all, 15% have gaps in use, and 27% use their method inconsistently or incorrectly.1

"Helping women who do not want to become pregnant to use contraceptives more effectively is sound public policy that will reduce unintended pregnancy," says Jennifer Frost, PhD, senior research associate at the Guttmacher Institute and the study's lead author. "In order to do that, it is critical to have a better understanding of what is preventing women from using contraception consistently and correctly — or even at all."

According to the new research, which analyzed responses from U.S. women and family planning providers, factors include:

  • Life changes. For more than 50% of women who have a gap in use of at least one month, researchers found that the period of nonuse coincides with an important life event, such as the beginning or end of a relationship, a move to a new home, a job change or a personal crisis.
  • Method problems. Nearly four in 10 contraceptive users are not very satisfied with their current method, research findings indicate. Dissatisfied users are more likely to put themselves at high risk for unintended pregnancy, by missing oral contraceptives or not using a condom every time, researchers found.
  • Ambivalence. Nearly one in four women who are not trying to become pregnant say they would be very pleased if they found out they were pregnant. Women who are the least motivated to avoid pregnancy also are the least likely to use oral contraceptives or to use the method consistently, research findings indicate.
  • Access. Many women report difficulty accessing contraceptive services or say they cannot afford more effective prescription methods of birth control.
  • Disparities. Having a low level of education, belonging to a racial or ethnic minority, or being on Medicaid are associated with contraceptive behavior that is likely to increase women's risk for unintended pregnancy, say researchers. However, more important than poverty status, race, or ethnicity are women's attitudes toward pregnancy, their satisfaction with their method, and their experiences with contraceptive service providers, they note.1

Finding the "right" contraceptive method is not a one-time decision for women; rather, it is a series of choices as women's life circumstances and contraceptive needs change, says Frost.

"Helping women decide which contraceptive method to use can be a starting point for providers to offer ongoing counseling and support to their patients," she notes. "The more we can remove the remaining barriers to consistent use, the better we will be at ensuring that all women can avoid unwanted pregnancies and plan the children they want, when they want them."

How to check for gaps

How can you determine whether a woman has been consistently using her method of birth control? Consider this approach to assessing contraceptive use from Katharine O'Connell, MD, MPH, assistant clinical professor of obstetrics and gynecology at New York City-based Columbia University Medical Center:

— Ask "What method of contraception are you using now?" O'Connell says this open-ended approach allows the clinician to follow with a question on what has been used in the last year to get a sense if there has been continuous use.

— Ask "Did you take any breaks?" Try to stay away from a "loaded" word such as "gaps," she suggests. "[The word] 'gap' might sound like she did something wrong, and I don't want her to feel like she has to lie to me because that's the answer I want to hear," O'Connell explains.

"We find that when people have a life crisis, have a stop in a relationship, get older, there are so many reasons why it just isn't natural, it isn't easy to stay on a method," she says.

— If a woman indicates there was a break in contraceptive use, ask more questions to determine what led to it.

— If the woman is on oral contraceptives and says she was off pills for a few months, ask her questions such as, "Did you run out of refills?" and, "Was there a problem with the method itself?" advises O'Connell.

— Circle back to what the woman is using now. Check to see if the woman is satisfied with her current method, she suggests. Ask questions such as:

  • "How happy are you with it?"
  • "Do you have any problems taking it or using it?"
  • "Do you want to switch, or are you happy and do you want some refills?"

When 8% of typical users of oral contraceptives who don't want to become pregnant at beginning of the year become pregnant in the course of that year — which may be as many as 1 million women in the United States — one of the important emphases of family planning providers must be to carefully discuss and encourage the five contraceptives in the top tier of contraceptive effectiveness, found in the World Health Organization's Family Planning: A Global Handbook for Providers, says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta.2 (Editor's note: The entire guide may be downloaded free of charge online. Go to the web site, Click on "Health Topics," "Contraception," "Family Planning: Department of Reproductive Health and Research Providers," and "Family Planning: A Global Handbook For Providers.")

Hatcher says these top five are possible choices for women who want to have more children:

  • the contraceptive implant (Implanon, Organon; Roseland, NJ);
  • vasectomy;
  • levonorgestrel intrauterine system (Mirena IUS; Bayer HealthCare Pharmaceuticals, Wayne, NJ);
  • female sterilization;
  • the copper-bearing intrauterine device (ParaGard IUD, Duramed, a subsidiary of Barr Pharmaceuticals; Pomona, NY).

The reversible options (implant, IUS, and IUD) are good for those women who do want more children at some other point in time, Hatcher says.

Policy changes in the works

In the Guttmacher Institute report, public and private providers note one of the most important things they can do to improve patients' contraceptive use is to provide more and better counseling. Nearly half of private providers report that changing insurance reimbursement to allow more time for counseling would help achieve that goal.1

Policy-makers and private insurers can work to increase public funding and private insurance coverage for family planning services, particularly counseling services that can help identify the factors in women's lives that put them at increased risk of unintended pregnancy, say the Guttmacher Institute researchers.

With a projected increase in Title X funding set to be enacted this session by Congress, family planning services might get some much-needed assistance in meeting unmet needs, says Sharon Camp, PhD, Guttmacher Institute president and CEO. She also remains hopeful that legislation pending in Congress, the Unintended Pregnancy Reduction Act, will help eliminate the barrier of the Medicaid waiver process. If passed, the legislation will give states authority to expand their coverage of Medicaid family planning services to individuals up to the same income level used by the state to determine eligibility for pregnancy-related care, on a permanent basis and without the need for a waiver.


  1. Frost JJ, Darroch JE, Remez L. Improving Contraceptive Use in the United States. New York City: Guttmacher Institute; 2008.
  2. World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), INFO Project. Family Planning: A Global Handbook for Providers. Baltimore and Geneva: CCP and WHO; 2007.