Estimated reductions in unintended pregnancy among Delaware Title X family planning clients after a contraceptive access intervention
Nearly half of all pregnancies in the United States are unintended, and unplanned pregnancies are linked to poor health outcomes for women and their children. One strategy to reduce unintended pregnancy and promote better outcomes for women and children is to increase the use of effective contraceptive methods among women seeking to avoid pregnancy. Child Trends’ examination of Title X clinics in Delaware suggests that increased use of highly effective contraception can reduce unintended pregnancy.
In December 2014, Upstream USA—a nonprofit whose mission is to ensure that all women have convenient access to the full range of contraceptive methods—launched Delaware Contraceptive Access Now (Delaware CAN), a statewide initiative to reduce unintended pregnancy by increasing the use of effective contraceptive methods. Upstream commissioned Child Trends to examine how contraceptive use among family planning clients at Title X clinics in Delaware changed during the implementation of Delaware CAN. Child Trends then input contraceptive data into the microsimulation model FamilyScape 3.0 to project how the unintended pregnancy rate among this population may have changed based on the observed shifts in method use.
As reported in a Child Trends research brief, from 2014 to 2016, there was a substantial increase in the use of long-acting reversible contraception (LARC), defined as IUDs and implants, among Delaware Title X family planning clients ages 20–39. Our simulations projected that this increase in effective contraceptive use, along with a decrease in no-method use, was associated with an estimated 15 percent decline in unintended pregnancy among this population. By comparison, we found only a small increase in LARC use and a minor decrease in estimated unintended pregnancy for women at Title X clinics nationwide.
Following the release of the Title X family planning data for 2017, we have now updated our findings with an additional year of data. These recently released Title X contraceptive use data suggest that rates of LARC use continued to increase among clients at Title X family planning clinics in Delaware from 2016 to 2017, and thus the simulated unintended pregnancy rate for this population continued to fall. Increases in LARC use and projected decreases in unintended pregnancy among Delaware Title X family planning clients remain greater than those observed among clients nationwide.
- Using available contraceptive data from 2014 to 2017, LARC use increased from 13.7 to 31.5 percent among Delaware Title X family planning clients ages 20 to 39 (see Figure 1).
- This increase was offset by a decrease in the use hormonal methods such as birth control pills, patch, and ring, and a decrease in condom use. For more information, see Tables 1 and 2 at the end of the blog with full contraceptive method distributions for Delaware and U.S.
- In Delaware, this observed movement from moderately effective methods to highly effective LARCs, paired with a small decrease in non-use (a reduction of 2.5 percentage points from 2014 to 2017), was linked to a substantial simulated decrease (24.2 percent) in the unintended pregnancy rate among this population from 2014 to 2017 (as predicted by the FamilyScape model, see Figure 2).
- Similar analyses of changes in method use among Title X family planning clients nationwide found a smaller increase in LARC use—from 13.6 percent to 19.9 percent—and no decrease in non-use from 2014 to 2017. FamilyScape simulated a decrease in unintended pregnancy of 3.0 percent during the same period.
The primary limitation of this analysis is that Delaware’s statewide Title X data are missing contraceptive information data for a large percentage of women. In 2014, 43 percent of women in our sample were categorized as Method Unknown, a figure that declined to 27 percent in 2015 and 2016, and to 25 percent in 2017. Women categorized as Method Unknown were excluded from our analysis—implicit in this approach is the assumption that the distribution of methods used by these women matched the distribution we calculated with the data available. If this were not the case—and if the methods used by women with missing data changed over time—we could be over- or underestimating the improvement in LARC use over time, as well as changes in other method categories. For instance, post-intervention, Title X providers may have had an incentive to ensure that women using LARCs were reported, thus overestimating the improvement in LARC use observed in the available Title X data. One focus of our ongoing research on this topic will be further analyses to assess the sensitivity of these findings to varying assumptions about the distribution of method mix for those whose method is unknown.
A second limitation of our study is that it does not incorporate an experimental research design. This means that we cannot isolate the impact of Delaware CAN, nor was that the intent of the analysis. However, Delaware’s Title X data suggest that the use of LARC methods has increased substantially since Upstream’s intervention began, representing a greater increase than we estimated among women at Title X clinics nationwide. Using the FamilyScape model, we project that this improvement in contraceptive use is linked to a meaningful decrease in the unintended pregnancy rate among Title X clients, while the rate among nationwide Title X clients is estimated to have dropped less notably during the study period.
FamilyScape Simulation Model
More information about FamilyScape and the methods used in our analysis can be found in Child Trends’ FamilyScape webpage and the original research brief. FamilyScape 3.0 is a microsimulation tool that allows the user to model the impacts of behavioral changes (e.g., an increase in the use of long-acting reversible contraception) on critical family-formation outcomes. It realistically simulates the key antecedents of pregnancy (sexual activity, contraceptive use, and female fecundity) and many of its important outcomes (such as pregnancy and childbearing within and outside of marriage, children’s chances of being born into poverty, and abortion). FamilyScape is designed to reproduce real-world fertility-related behaviors; for instance, the model incorporates the typical-use failure and continuation rates for birth control methods (typical-use failure rates account for incorrect and inconsistent use, as opposed to theoretical perfect-use failure rates estimated during clinical trials). Additional studies are available to explain how FamilyScape was developed and validated, and how it has been used to simulate pregnancy rates in the context of other interventions.