Background
While the rate of unintended pregnancy has declined in the United States in recent years, unintended pregnancy among teens in the United States is the highest among industrialized nations, and disproportionately affects minority teens.
Objective
Our objective of this secondary analysis was to estimate the risk of unintended pregnancy for both Black and White teens age 15-19 years when barriers to access, cost, and knowledge are removed. Our hypothesis was that the Black-White disparities would be reduced when access, education, and cost barriers are removed.
Study Design
We performed an analysis of the Contraceptive CHOICE Project database. CHOICE is a longitudinal cohort study of 9256 sexually active girls and women ages 14-45 years in the St Louis, MO, region from 2007 through 2013. Two measures of disparities were used to analyze teenage pregnancy rates and pregnancy risk from 2008 through 2013 among teens ages 15-19 years. These rates were then compared to the rates of pregnancy among all sexually active teens in the United States during the years 2008, 2009, 2010, and 2011. We estimated an absolute measure (rate difference) and a relative measure (rate ratio) to examine Black-White disparities in the rates of unintended pregnancy.
Results
While national rates of unintended pregnancy are decreasing, racial disparities in these rates persist. The Black-White rate difference dropped from 158.5 per 1000 in 2008 to 120.1 per 1000 in 2011; however, the relative ratio disparity decreased only from 2.6-2.5, suggesting that Black sexually active teens in the United States have 2.5 times the rate of unintended pregnancy as White teenagers. In the CHOICE Project, there was a decreasing trend in racial disparities in unintended pregnancy rates among sexually active teens (age 15-19 years): 2008 through 2009 (rate difference, 18.2; rate ratio, 3.7), 2010 through 2011 (rate difference, 4.3; rate ratio, 1.2), and 2012 through 2013 (rate difference, –1.5; rate ratio, 1.0).
Conclusion
When barriers to cost, access, and knowledge were removed, such as in the Contraceptive CHOICE Project, Black-White disparities in unintended pregnancy rates among sexually active teens were reduced on both absolute and relative scales. The rate of unintended pregnancy was almost equal between Black and White teens compared to large Black-White disparities on the national level.
Introduction
Over the past several years, the US birth rate has declined steadily. However, a disproportionate number of those births occur among Black and Hispanic women. Of the 3 million unintended pregnancies that occur each year in the United States, Black women are 3 times more likely and Hispanic women are twice as likely to have an unintended pregnancy in comparison to White women. The US teen pregnancy rate is among the highest in the developed world, and the risk of death associated with these pregnancies is one third higher than for women 20-24 years of age. Teenagers are at particularly high risk for unintended pregnancy as they experience increased barriers to accessing contraceptives such as financial constraints, misinformation about long-acting reversible contraception (LARC), and unclear legal frameworks surrounding confidentiality for minors.
Many unintended pregnancies occur because of incorrect or inconsistent use of contraceptives, and nonuse of contraception. Incorrect, inconsistent, and nonuse of contraception are highest among non-Hispanic Black and Hispanic women when compared to other racial/ethnic groups. However, high rates of unintended pregnancies among minorities cannot solely be attributed to contraceptive failure and nonuse.
Health care disparities also contribute to the high rates of unintended pregnancy seen among Black and Hispanic women. Disparities in health usually occur at 3 points: (1) exposures to stressors throughout the life course, (2) access to medical care, and (3) quality of care received. Addressing the social determinants of health disparities by eliminating access, education, and cost barriers have the potential to significantly reduce racial disparities in health outcomes. Non-Hispanic Blacks and Hispanics are also more likely to have lower education levels, poor quality of education, lower income, and lack health insurance in comparison to Whites. This is significant as several studies using data from the National Survey of Family Growth in 2006 through 2008 showed income and education attainment to be significant predictors for unintended pregnancy.
Removing barriers to the most effective forms of contraception could reduce unintended teen pregnancies, improve the reproductive health of non-Hispanic Black and Hispanic women, and promote educational and career advancement. The purpose of this study is to examine the effects that removing cost, access, and knowledge barriers would have on non-Hispanic Black-White disparities in rates of unintended pregnancy.
Materials and Methods
The Contraceptive CHOICE Project is a prospective cohort study; 9256 women and girls were enrolled. The study sought to reduce unintended pregnancies among girls and women ages 14-45 years by informing and educating them about the most effective reversible methods of contraception: LARC including intrauterine devices and the contraceptive implant. Participants were recruited from medical clinics, study flyers, and newspaper advertisements. Participants were enrolled from August 2007 through September 2011, and were provided the contraceptive method of their choice at no cost for 2-3 years, depending on the date of enrollment. The Human Research Protection Office at Washington University in St Louis School of Medicine approved the protocol of the CHOICE Project.
Women and girls were eligible to participate in the CHOICE Project if they did not want to become pregnant within the coming year, were between 14-45 years of age, were sexually active with a male or were going to be sexually active in the next 6 months, lived in the St Louis area, and spoke English or Spanish. Those who had undergone a sterilization procedure or hysterectomy were excluded from the study. Before enrolling in the study, all participants gave written informed consent to join the study. Girls age <18 years gave written assent and a guardian or parent gave written consent. If minors sought contraception without parental knowledge, they could enroll using a waiver of parental consent.
All participants received contraceptive counseling that presented contraceptives in order of most to least effective. In addition, the counseling reviewed risks, side effects, and benefits associated with each method. Participants choose the appropriate method of contraception for themselves and were offered same-day insertion (when applicable) unless the patient desired an intrauterine device and currently had cervicitis or if pregnancy could not be ruled out.
Participants conducted telephone interviews with study staff at 3 and 6 months and every 6 months until completion of 2-3 years of follow-up, depending on when participants enrolled in the study. During these interviews, information regarding demographic characteristics, pregnancy outcomes, contraceptive method use and satisfaction, and reproductive history of participants was obtained. The participants self-reported their race and ethnicity during these interviews. All pregnancies were documented in a pregnancy log as well as the contraceptive method that the participant was using at the time of the pregnancy. In addition, if the outcome of the pregnancy was known at the time of the survey, this information was documented.
Estimates for pregnancy rates among sexually active teens in the United States were calculated from the yearly birth rate, abortion rate, and miscarriage rate for each year from 2008 through 2011 by race for non-Hispanic Whites and Blacks ages 15-19 years. Birth rates were obtained from National Vital Statistics reports, a project of the National Center for Health Statistics. The abortion rate comes from the statistics released by the Guttmacher Institute. The number of miscarriages is estimated to be 20% of births and 10% of abortions (miscarriage rate = birth rate × 0.2 + abortion rate × 0.1). The pregnancy rate is the sum of the birth rate, abortion rate, and the miscarriage rate, expressed in pregnancies per 1000 teens. Using data from the National Survey of Family Growth, we calculated the percent of teens age 15-19 years who had ever had sex by race to develop race-specific estimates. This percentage is multiplied by the number of teens (age 15-19 years) of each race to estimate the number of sexually active teens by race. The number of sexually active teenagers in the United States is the denominator and the number of pregnancies is the numerator of the race-specific estimates. Because the national rates are calculated for each year, they are expressed as pregnancies per 1000 person-years.
CHOICE estimates of pregnancy rates among sexually active teens are calculated by dividing the number of pregnancies by person-years contributed by participants aged 15-19 years and multiplied by 1000 to get rate per 1000 person-years. Given the low number of pregnancies in some years, rates are calculated for 2-year periods (2008 through 2009, 2010 through 2011, 2012 through 2013) ( Table ). Details of the assessment of unintended pregnancies in CHOICE can be found in Secura et al.
| United States | CHOICE Project | ||||||
|---|---|---|---|---|---|---|---|
| 2008 | 2009 | 2010 | 2011 | 2008 through 2009 | 2010 through 2011 | 2012 through 2013 | |
| White | 101.0 | 96.2 | 87.7 | 82.4 | 6.8 | 27.2 | 32.0 |
| Black | 259.5 | 242.1 | 220.8 | 202.5 | 25.1 | 31.5 | 30.5 |
We examined Black-White disparities in teenage (ages 15-19 years) pregnancy rates in US population estimates and CHOICE Project estimates using 2 disparities measures: 1 absolute (rate difference [RD]) and 1 relative (rate ratio [RR]) measure. RD is the absolute difference between the unintended teenage pregnancy rates for Blacks ( r B ) and Whites ( r W ) and is calculated as r B – r W . The RR is the relative difference and is calculated as r B /r W . RR measures the relative difference in the rates of the best and worst group at each time point.
Materials and Methods
The Contraceptive CHOICE Project is a prospective cohort study; 9256 women and girls were enrolled. The study sought to reduce unintended pregnancies among girls and women ages 14-45 years by informing and educating them about the most effective reversible methods of contraception: LARC including intrauterine devices and the contraceptive implant. Participants were recruited from medical clinics, study flyers, and newspaper advertisements. Participants were enrolled from August 2007 through September 2011, and were provided the contraceptive method of their choice at no cost for 2-3 years, depending on the date of enrollment. The Human Research Protection Office at Washington University in St Louis School of Medicine approved the protocol of the CHOICE Project.
Women and girls were eligible to participate in the CHOICE Project if they did not want to become pregnant within the coming year, were between 14-45 years of age, were sexually active with a male or were going to be sexually active in the next 6 months, lived in the St Louis area, and spoke English or Spanish. Those who had undergone a sterilization procedure or hysterectomy were excluded from the study. Before enrolling in the study, all participants gave written informed consent to join the study. Girls age <18 years gave written assent and a guardian or parent gave written consent. If minors sought contraception without parental knowledge, they could enroll using a waiver of parental consent.
All participants received contraceptive counseling that presented contraceptives in order of most to least effective. In addition, the counseling reviewed risks, side effects, and benefits associated with each method. Participants choose the appropriate method of contraception for themselves and were offered same-day insertion (when applicable) unless the patient desired an intrauterine device and currently had cervicitis or if pregnancy could not be ruled out.
Participants conducted telephone interviews with study staff at 3 and 6 months and every 6 months until completion of 2-3 years of follow-up, depending on when participants enrolled in the study. During these interviews, information regarding demographic characteristics, pregnancy outcomes, contraceptive method use and satisfaction, and reproductive history of participants was obtained. The participants self-reported their race and ethnicity during these interviews. All pregnancies were documented in a pregnancy log as well as the contraceptive method that the participant was using at the time of the pregnancy. In addition, if the outcome of the pregnancy was known at the time of the survey, this information was documented.
Estimates for pregnancy rates among sexually active teens in the United States were calculated from the yearly birth rate, abortion rate, and miscarriage rate for each year from 2008 through 2011 by race for non-Hispanic Whites and Blacks ages 15-19 years. Birth rates were obtained from National Vital Statistics reports, a project of the National Center for Health Statistics. The abortion rate comes from the statistics released by the Guttmacher Institute. The number of miscarriages is estimated to be 20% of births and 10% of abortions (miscarriage rate = birth rate × 0.2 + abortion rate × 0.1). The pregnancy rate is the sum of the birth rate, abortion rate, and the miscarriage rate, expressed in pregnancies per 1000 teens. Using data from the National Survey of Family Growth, we calculated the percent of teens age 15-19 years who had ever had sex by race to develop race-specific estimates. This percentage is multiplied by the number of teens (age 15-19 years) of each race to estimate the number of sexually active teens by race. The number of sexually active teenagers in the United States is the denominator and the number of pregnancies is the numerator of the race-specific estimates. Because the national rates are calculated for each year, they are expressed as pregnancies per 1000 person-years.
CHOICE estimates of pregnancy rates among sexually active teens are calculated by dividing the number of pregnancies by person-years contributed by participants aged 15-19 years and multiplied by 1000 to get rate per 1000 person-years. Given the low number of pregnancies in some years, rates are calculated for 2-year periods (2008 through 2009, 2010 through 2011, 2012 through 2013) ( Table ). Details of the assessment of unintended pregnancies in CHOICE can be found in Secura et al.
