Contraceptive Use and Risk of Unintended Pregnancy Among Females in the United States: Trends and Characteristics Between 2019 and 2022

Abstract

Background: Little is known about women’s contraceptive use in the United States during the novel coronavirus (“COVID-19”) pandemic and the risk of unintended pregnancy. Methods: We compared the weighted response rates on contraception use for female respondents aged 18–44 from the Behavioral Risk Factor Surveillance System (BRFSS) between 2019 and 2022. Results: Our study reveals a significant increase of 16.1% (CI = 0.145, 0.177) in the proportion of women using contraception in 2022 as compared to 2019. The largest increase in the use of non-reversible contraception was seen in the proportion of female sterilization, at 3.0% (CI = 0.017, 0.043), mostly attributed to non-Hispanic Black individuals with a 12% increase (CI = 0.046, 0.198). The largest decrease was seen in the use of condoms, at 7.4% (CI = −0.094, −0.055). This was driven by both non-Hispanic Black and multiracial groups, each experiencing a 19% decrease (CI = −0.251, −0.127; CI = −0.304, −0.068, respectively). The proportion of women at risk of unintended pregnancy increased by 3.7% (CI = 0.010, 0.063). These increases were observed among those with an income of less than USD 15k, showing a 14.9% increase (CI = 0.037, 0.262). Older females and those with Medicaid insurance were more likely to use female sterilization. Hispanics, college graduates, and those with Medicaid insurance were more likely to use condoms. Non-White females and those without annual checkups were more at risk of unintended pregnancy. Conclusions: Contraceptive methods shifted among females with slightly increased sterilization in the years 2019 to 2022.

1. Introduction

According to a report from 2022, 90% of U.S. females from the age of 18 to 64 years old have used contraception at some point in their reproductive years, and 85% have used contraception to prevent pregnancy [1]. Despite the use of contraception to prevent pregnancy, a significant number of unintended pregnancies result from inconsistent or incorrect use of contraception [2]. This can occur as women’s choices regarding contraception may shift over time, influenced by variations in the mechanisms of action, effectiveness, cost, and accessibility of different contraceptive methods [3]. Research suggests that 76% of females report using more than one contraceptive method throughout their lifetime [1]. As women switch between contraceptive methods, they may experience gaps in contraception and face the risk of unintended pregnancy [1,4,5]. Indeed, large numbers of unintended pregnancies result from not using contraception [6,7]. For example, in 2022, 17% of sexually active females who said they were not trying to become pregnant had not used contraception [1]. The latter group may be particularly at risk of unintended pregnancies. Accordingly, to minimize these risks or to help women with their reproductive health care needs, it is essential to understand their contraceptive choices [8,9,10,11].

In reviewing the literature, we found two recent studies—one spanning from 2008 to 2014 and the other from 2017 to 2019—that examined trends and characteristics in contraceptive method use in the United States [12,13]. The common findings from both studies suggest a number of things. Approximately 60–65% of all women use contraception, and the overall use has not changed over the years. While some of the most prevalent methods included pills, condoms, and female sterilization, there was an increasing trend in the proportion of women opting for long-acting reversible contraceptives (LARCs), especially intrauterine devices (IUDs). Additionally, preferences for contraception methods varied across age, race/ethnicity, and educational attainment groups [12,13]. Despite this information, these studies are limited in some ways. First, they were both drawn from the National Survey of Family Growth (NSFG), which is more representative of individuals with lower education, lower income, a higher rate of cohabiting, and lower married status as compared to other surveys [14]. Second, only one study reported individuals at risk of unintended pregnancy [12]. The limitations of these two studies are consequential in two ways. First, while these studies provide evidence on contraceptive use and examine which methods are preferred, they are limited to particular snapshots in time. Secondly, such preferences in contraception may shift significantly in response to external factors and events, such as policy changes that impact perceived barriers, or pandemic conditions—for example, for the latter, due to the social impacts of quarantine.

In this study, we analyze a newer dataset that addresses reproductive health planning and spans the time of the novel coronavirus (“COVID-19”) pandemic [14]. The aim of our study is threefold. The first is to examine any changes in the use of contraceptives, as well as the risk of unintended pregnancy, across the years 2019 and 2022. The second is to examine the underlying factors contributing to these changes. The third is to analyze the individual characteristics associated with contraceptive method use and the risk of unintended pregnancy. For the third aim of the study, we only focus on the year 2022 because the findings for the year 2019 are available through previous studies [12]. Although the BRFSS was conducted in 2020 during the pandemic, which started in March 2020, we selected pre-pandemic (2019) and 2022 data for comparison for several reasons. First, the impact of the pandemic on women’s reproductive health care needs would likely be revealed, as evidence shows there was a disruption in continued access to contraception during the pandemic [15,16,17]. Second, after the Supreme Court overturned Roe v. Wade in June 2022 [18], not only was access to abortion restricted in many states, but also access to effective pregnancy prevention methods, such as emergency pills and LARCs, was restricted [1]. Third, over the past few years there have been changes in fertility patterns including drops in pregnancy and birth rates, which could be described by variations in the use of contraceptive methods [13,19,20].

2. Materials and Methods

This study analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) for the years 2019 and 2022. The BRFSS is an annual telephone health survey that collects state data on the behavioral health risks of individuals. The survey is conducted monthly and includes all 50 states as well as the District of Columbia. It is considered the largest continuously conducted health survey system in the world [21]. The BRFSS 2019 and 2022 are useful for our analysis for several reasons. First, they include various questions regarding family planning that ask about the use and types of contraception employed by the respondents. Second, they provide various characteristics that help us examine changes across females with various social and demographic characteristics. Third, to the best of our knowledge, they have not yet been investigated concerning questions regarding contraception and family planning.

We limited the study to female respondents with sexual encounters. Our primary outcome of interest that indicates the use of contraception comes from a family planning question that surveyed respondents as to whether they had done anything to keep themselves from getting pregnant during their last sexual encounter (Yes/No). The second set of outcomes was obtained from a question about the methods that participants or their partners used to keep them from getting pregnant. Specific methods include female sterilization; male sterilization; contraceptive implants; IUDs; pills, rings, patches, and shots; condoms (male or female); diaphragms, cervical caps, sponges, foams, jellies, films, or creams; natural family planning or rhythm (not having sex at certain times); withdrawal or pulling out; and other methods. We dichotomized these outcomes labeled as “Yes” or “No”. The third outcome of interest defining all women at risk of unintended pregnancy was created by identifying women who did not use any contraceptive methods during their last sexual encounter yet were neither pregnant nor attempting to conceive and did not have any sterility or infertility issues [12].

We examined outcomes across a range of respondents’ social demographic and health characteristics. The characteristic variables include age (18–24, 25–29, 35–39, or 40–44), race/ethnicity (non-Hispanic White, Black, other race, or multiracial, or Hispanic), annual household income (less than 15k, 15 to <25k, 25 to <35k, 35 to <50k, or 50k or more USD), employment (categorized as currently employed, including those employed for wages or self-employed, or unemployed, including those out of work, homemaking, retired, or unable to work), educational attainment (no high school diploma, high school, some college, or college graduate), marital status (categorized as currently married or not married, including those divorced, widowed, separated, never married, or cohabiting), insurance coverage (private, self-pay/uninsured, Medicaid, and other types of coverage), routine checkup (categorized into a binary format and labeled as “Yes” or “No”, where “Yes” includes those having had a checkup within the past 12 months), and general health (includes adults who self-defined their health conditions as excellent, very good, good, fair, or poor health).

Statistical Analysis

For each of the outcomes, we estimated the weighted response rates in the years 2019 and 2022 and report their significant differences between the two years at p < 0.05. We also estimated differences stratified by individual characteristics. To highlight the association between an individual’s characteristics and the use of a certain method or being at risk of unintended pregnancy, we also used a multivariable logistic regression and estimated adjusted odds ratios (aoRs) for the 2022 sample. In the text, we report confidence intervals (CIs) at a 95% level of confidence. All analyses were conducted using the “svy” command prefix within Stata 18.0.

3. Results

The baseline demographic characteristics of the survey respondents are provided in Table 1. With respect to the first aim of the study, Table 1 displays the proportions of contraceptive users and non-users overall and for specific categories in 2019 and 2022, along with the variations in use between the two years. The finding showed that, overall, ~63% of women in 2019 and ~79% in 2022 were using some type of contraception, indicating a significant increase of 16% (CI = 0.145, 0.177) in the proportion of women using a contraceptive method in 2022. Similar declines were observed in non-users between the years studied. Among contraceptive users, there was an increase in the proportion of female sterilization, by 3.0% (CI = 0.017, 0.043); male sterilization, by 2.4% (CI = 0.014, 0.034); IUDs, by 2.1% (CI = 0.007, 0.036); natural family planning, by <1% (CI = 0.004, 0.015); and withdrawal, by 4.3% (CI = 0.033, 0.053). Also, the findings show a decrease in the proportion of users of pills, rings, patches, and shots, by ~7% (CI = −0.084, −0.047), and users of condoms, by ~7% (CI = −0.094, −0.055). No significant changes were observed for other contraceptive methods. Lastly, the findings show that among non-users, the proportion of women at risk of unintended pregnancy increased by 3.7% (CI = 0.010, 0.063).

Table 1. Trends in the proportion of contraceptive use between 2019 (n = 30,707; weighted n = 22,510,150) and 2022 (n = 12,718; weighted n = 11,171,186) among all women aged 18–44, women at risk of unintended pregnancy, and contraceptive users. IUD = intrauterine device; CC = cervical cap.

	2019	%	2022	%	Change	%	p Value
Among all women
Using a contraceptive method	0.633	63.3%	0.794	79.4%	0.161	16.1%	<0.001 **
Not using a contraceptive method	0.367	36.7%	0.206	20.6%	−0.161	−16.1%	<0.001 **
Among contraceptive users, percentage using each method
Female sterilization	0.070	7.0%	0.100	10.0%	0.03	3.0%	<0.001 **
Male sterilization	0.061	6.1%	0.085	8.5%	0.024	2.4%	<0.001 **
Contraceptive implant	0.037	3.7%	0.041	4.1%	0.004	0.4%	0.460
IUD	0.139	13.9%	0.160	16.0%	0.021	2.1%	<0.01 **
Pills, rings, patches, and shots	0.304	30.4%	0.238	23.8%	−0.066	−6.6%	<0.001 **
Condoms (male or female)	0.294	29.4%	0.220	22.0%	−0.074	−7.4%	<0.001 **
Diaphragm, CC, sponge, foam, jelly, film, or cream	0.002	0.2%	0.002	0.2%	0	0%	0.418
Natural family planning	0.004	0.4%	0.013	1.3%	0.009	0.9%	<0.001 **
Withdrawal or pulling out	0.021	2.1%	0.064	6.4%	0.043	4.3%	<0.001 **
Other method	0.064	6.4%	0.073	7.3%	0.009	0.9%	0.178
Among non-contraceptive users, proportion at risk of unintended pregnancy *
Women at risk of pregnancy	0.095	9.5%	0.132	13.2%	0.037	3.7%	<0.01 **

* Women at risk of unintended pregnancy include women who, in the last time they had sexual intercourse, had not used any contraceptive measures yet were not pregnant or trying to conceive and were not sterile or infertile. ** Statistically significant.

With respect to the second aim of the study, Table 2 displays which characteristics led to the greatest changes (increases or decreases) in the use of a specific contraceptive method and the rate of individuals at risk of unintended pregnancy. The largest change in female sterilization occurred among non-Hispanic Black individuals, with a 12% increase (CI = 0.046, 0.198) since 2019. For male sterilization, the largest change was observed among (partners of) females aged 40–44, with a 6% increase (CI = 0.019, 0.093). Among those using IUDs, the largest change was among individuals aged 25–29, with a 5% increase (CI = 0.009, 0.087), as well as among those with private coverage, with a similar 5% increase (CI = 0.021, 0.084). For individuals using pills, rings, patches, or shots, the largest change occurred among those with incomes less than USD 15k, showing a substantial 17% decrease (CI = −0.241, −0.106). For condom users, both non-Hispanic Black and multiracial groups experienced a notable 19% decrease ((CI = −0.251, −0.127) and (CI = −0.304, −0.068), respectively). Use of the withdrawal method increased by 7% among non-Hispanic Black individuals (CI = 0.044, 0.103) and those with fair health conditions (CI = 0.015, 0.125). Among women at risk of unintended pregnancy, the most significant change was observed among those with an income less than USD 15k, showing a ~15% increase (CI = 0.037, 0.262).

Table 2. Proportional change in current contraceptive users by method and selected user characteristics, 2019–2022. IUD = intrauterine device; NFP = natural family planning; PRPS = pills, rings, patches, and shots; RUP = risk of unintended pregnancy.

	Female Sterilization		Male Sterilization		IUD		PRPS		Condoms		NFP		Withdrawal		RUP
	Change	p Value	Change	p Value	Change	p Value	Change	p Value	Change	p Value	Change	p Value	Change	p Value	Change	p Value
Age
18 to 24	0.01	0.25	−0.01	0.15	0.04	<0.01 **	−0.09	<0.001 **	−0.03	0.22	0.01	<0.05 **	0.05	<0.001 **	0.012	0.742
25 to 29	0.01	0.14	0.01	0.10	0.05	<0.05 **	−0.07	<0.01 **	−0.07	<0.01 **	0.01	<0.01 **	0.05	<0.001 **	0.020	0.538
30 to 34	0.04	<0.01 **	0.01	0.43	0.01	0.61	−0.07	<0.001 **	−0.08	<0.001 **	0.01	<0.001 **	0.04	<0.01 **	−0.005	0.817
35 to 39	0.03	0.18	0.03	<0.05 **	0.01	0.46	−0.03	0.10	−0.05	<0.05 **	0.01	<0.05 **	0.04	<0.001 **	0.075	<0.05 **
40 to 44	0.04	<0.05 **	0.06	<0.01 **	−0.02	0.17	−0.01	0.59	−0.12	<0.001 **	0.01	0.30	0.04	<0.01 **	0.065	<0.05 **
Race/Ethnicity
Non-Hispanic White	0.02	<0.001 **	0.04	<0.001 **	0.04	<0.001 **	−0.07	<0.001 **	−0.07	<0.001 **	0.01	<0.001 **	0.04	<0.001 **	0.002	0.861
Non-Hispanic Black	0.12	<0.001 **	0.02	0.07	0.01	0.56	−0.06	<0.05 **	−0.19	<0.001 **	0.01	0.09	0.07	<0.001 **	0.025	0.451
Non-Hispanic other	0.02	0.45	0.02	0.25	0.02	0.70	−0.03	0.53	−0.10	<0.05 **	0.04	0.18	0.03	<0.05 **	0.059	0.340
Non-Hispanic multiracial	0.08	0.08	−0.01	0.61	0.10	0.07	−0.07	0.17	−0.19	<0.001 **	0.00	0.39	0.04	0.25	0.112	0.229
Hispanic	0.01	0.32	0.02	0.07	−0.01	0.54	−0.06	<0.05 **	−0.03	0.27	0.01	<0.01 **	0.04	<0.05 **	0.039	0.172
Income (×1000) USD
Less than 15	0.06	0.05	0.02	0.31	−0.01	0.69	−0.17	<0.001 **	−0.01	0.88	0.02	<0.05 **	0.06	<0.001 **	0.149	<0.01 **
15 to 25	0.06	<0.001 **	0.00	0.84	0.03	0.20	−0.06	<0.05 **	−0.11	<0.001 **	0.00	0.60	0.04	<0.001 **	0.018	0.571
25 to 35	0.06	<0.01 **	0.03	<0.01 **	0.03	0.20	−0.03	0.26	−0.11	<0.001 **	0.01	<0.05 **	0.04	0.06	−0.020	0.552
35 to 50	0.08	<0.05 **	0.00	0.74	0.03	0.18	−0.08	<0.01 **	−0.06	0.05	0.01	0.19	0.05	<0.01 **	0.079	0.083
50 or more	0.02	0.05	0.03	<0.01 **	0.01	0.20	−0.06	<0.001 **	−0.06	<0.001 **	0.01	<0.05 **	0.04	<0.001 **	0.035	0.061
Employment
Currently employed	0.03	<0.001 **	0.03	<0.001 **	0.02	<0.05 **	−0.07	<0.001 **	−0.07	<0.001 **	0.01	<0.01 **	0.04	<0.001 **	0.030	0.061
Unemployed	0.03	<0.05 **	0.02	0.06	0.02	<0.05 **	−0.06	<0.01 **	−0.09	<0.001 **	0.01	<0.01 **	0.04	<0.001 **	0.055	<0.05 **
Education
No high school diploma	0.08	0.08	0.03	0.08	0.01	0.82	−0.14	<0.001 **	−0.07	0.22	0.00	0.26	0.04	0.21	0.096	0.083
High school	0.04	<0.01 **	0.01	0.39	0.03	0.06	−0.04	0.05	−0.08	<0.001 **	0.00	0.33	0.04	<0.001 **	0.021	0.424
Some college	0.03	<0.001 **	0.03	<0.01 **	0.03	<0.05 **	−0.07	<0.001 **	−0.10	<0.001 **	0.02	<0.05 **	0.05	<0.001 **	0.004	0.782
College graduate	0.01	0.25	0.03	<0.001 **	0.02	0.14	−0.06	<0.001 **	−0.05	<0.001 **	0.01	<0.001 **	0.04	<0.001 **	0.064	<0.05 **
Marital status
Currently married	0.03	<0.05 **	0.03	<0.05 **	0.00	0.99	−0.04	<0.01 **	−0.05	<0.001 **	0.01	<0.05 **	0.03	<0.01 **	0.031	0.103
Unmarried	0.02	<0.001 **	0.01	<0.01 **	0.03	<0.001 **	−0.07	<0.001 **	−0.08	<0.001 **	0.01	<0.001 **	0.05	<0.001 **	0.045	<0.05 **
Insurance coverage
Private	0.02	0.056	0.04	<0.001 **	0.05	<0.001 **	−0.10	<0.001 **	−0.06	<0.01 **	0.01	0.113	0.04	<0.001 **	0.048	<0.05 **
Self-pay/uninsured	0.09	<0.001 **	0.02	0.272	0.05	0.072	−0.09	0.091	−0.15	<0.05 **	0.02	<0.001 **	0.04	0.070	0.056	0.203
Medicaid	0.03	0.213	0.02	0.138	−0.01	0.721	−0.08	<0.05 **	−0.04	0.273	0.01	<0.001 **	0.05	<0.01 **	0.096	<0.01 **
Other	−0.03	0.326	0.04	0.171	0.06	<0.05 **	−0.09	0.097	−0.12	<0.05 **	0.01	0.056	0.04	<0.01 **	0.004	0.892
Checkup
Yes	0.03	<0.001 **	0.03	<0.001 **	0.03	<0.01 **	−0.07	<0.001 **	−0.07	<0.001 **	0.01	<0.001 **	0.04	<0.001 **	0.026	0.074
No	0.04	<0.001 **	0.02	0.09	0.01	0.32	−0.07	<0.001 **	−0.10	<0.001 **	0.02	<0.05 **	0.06	<0.001 **	0.061	<0.05 **
General health
Excellent	0.06	<0.01 **	0.03	<0.01 **	0.00	0.95	−0.08	<0.001 **	−0.08	<0.001 **	0.00	0.09	0.02	<0.01 **	0.070	0.081
Very good	0.03	<0.001 **	0.02	<0.05 **	0.03	<0.05 **	−0.07	<0.001 **	−0.06	<0.001 **	0.02	<0.05 **	0.04	<0.001 **	0.025	0.200
Good	0.02	0.08	0.03	<0.01 **	0.03	<0.05 **	−0.05	<0.01 **	−0.09	<0.001 **	0.01	<0.001 **	0.05	<0.001 **	0.032	0.120
Fair	0.00	0.89	0.01	0.19	0.02	0.33	−0.06	<0.05 **	−0.06	0.14	0.00	0.19	0.07	<0.05 **	0.011	0.791
Poor	−0.01	0.85	0.02	0.42	0.05	0.27	−0.11	0.08	−0.15	<0.05 **	0.00	0.45	0.05	0.24	0.120	0.092

** Statistically significant.

With respect to the third aim of the study, Table 3 shows predictors of contraceptive users and non-users for specific methods and categories in the year 2022. Findings from each column are presented below. Adjusted odds ratios (aoRs) are presented in parentheses. To improve the readability of this study, reference groups (ref) are shown only once upon their initial introduction.

Table 3. Among current female contraceptive users aged 18–44, adjusted odds ratios (aoRs) from logistic regression assessing associations between user characteristics and use of individual methods, 2022. IUD = intrauterine device; NFP = natural family planning; PRPS = pills, rings, patches, and shots; RUP = risk of unintended pregnancy; NH = non-Hispanic.; UE = unemployed; HS = high school diploma; SC = some college; UM = unmarried; SP/UI = self-pay/uninsured.

	Female Sterilization		Male Sterilization		IUD		PRPS		Condoms		NFP		Withdrawal		RUP
	aoR	p Value	aoR	p Value	aoR	p Value	aoR	p Value	aoR	p Value	aoR	p Value	aoR	p Value	aoR	p Value
Age
18 to 24	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-
25 to 29	3.98	<0.001 **	4.72	<0.01 **	1.24	0.20	0.98	0.91	0.72	<0.01 **	1.58	0.35	1.23	0.37	0.67	0.29
30 to 34	8.09	<0.001 **	8.71	<0.001 **	0.92	0.58	0.71	<0.001 **	0.56	<0.001 **	1.13	0.79	1.12	0.61	0.56	0.11
35 to 39	12.50	<0.001 **	16.34	<0.001 **	0.87	0.42	0.62	<0.001 **	0.58	<0.001 **	0.89	0.85	0.92	0.72	0.88	0.72
40 to 44	13.91	<0.001 **	25.01	<0.001 **	0.81	0.20	0.51	<0.001 **	0.30	<0.001 **	1.75	0.42	0.87	0.62	0.75	0.42
Race/Ethnicity
NH White	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-
NH Black	1.16	0.61	0.27	<0.001 **	0.47	<0.001 **	0.69	<0.001 **	1.19	0.14	0.81	0.67	1.01	0.93	2.04	<0.05 **
NH other	0.67	0.27	0.32	<0.001 **	0.64	0.08	0.71	0.052	1.14	0.40	3.58	0.19	0.52	<0.05 **	2.78	<0.05 **
NH multiracial	1.69	0.20	0.40	<0.05 **	1.30	0.43	0.85	0.41	1.09	0.64	0.85	0.77	1.39	0.31	3.89	<0.01 **
Hispanic	0.83	0.21	0.98	0.89	0.88	0.30	0.92	0.48	1.81	<0.001 **	1.46	0.21	0.98	0.94	2.32	<0.001 **
Income × 1000
<15	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-
15 to <25	0.87	0.61	0.63	0.54	1.40	0.20	1.45	0.10	0.73	0.22	0.24	<0.05 **	0.68	0.29	0.52	0.09
25 to <35	0.75	0.29	1.04	0.95	1.44	0.14	1.37	0.14	0.55	<0.05 **	0.34	0.12	0.92	0.80	0.32	<0.01 **
35 to <50	1.01	0.97	1.05	0.93	1.37	0.20	1.31	0.21	0.60	<0.05 **	0.20	<0.05 **	0.91	0.81	0.76	0.60
50 or more	0.51	<0.01 **	1.68	0.41	1.41	0.14	1.34	0.16	0.49	<0.01 **	0.31	0.08	0.96	0.93	0.49	0.11
Employment Status
Employed	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-
UE	1.18	0.19	1.54	<0.001 **	1.12	0.30	1.20	0.06	1.05	0.71	0.82	0.58	1.16	0.41	0.87	0.59
Education
No HS	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-
HS	0.74	0.39	1.26	0.57	1.15	0.71	1.23	0.26	0.89	0.58	1.10	0.88	1.35	0.63	0.66	0.36
SC	0.83	0.61	2.29	<0.05 **	1.80	0.14	1.67	<0.01 **	1.02	0.88	4.38	<0.01 **	1.88	0.33	0.46	0.08
College graduate	0.49	0.07	2.19	<0.05 **	2.07	0.06	1.88	<0.001 **	1.51	<0.05 **	3.14	0.14	2.24	0.24	0.98	0.97
Marital Status
Married	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-
UM	0.50	<0.001 **	0.24	<0.001 **	0.78	<0.05 **	0.98	0.88	1.02	0.84	0.39	<0.01 **	0.83	0.28	1.32	0.23
Insurance Coverage
Private	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-
SP/UI	0.93	0.731	0.77	0.141	0.68	<0.01 **	0.84	0.138	0.63	<0.001 **	1.25	0.569	1.13	0.685	1.11	0.73
Medicaid	2.09	<0.001 **	1.22	0.331	0.97	0.856	1.30	<0.05 **	1.45	<0.01 **	1.86	0.097	2.30	<0.001 **	1.25	0.50
Other	0.60	<0.05 **	0.95	0.748	0.57	<0.01 **	0.83	0.156	0.65	<0.01 **	0.65	0.433	0.69	0.253	0.62	0.30
Checkup
Yes	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-
No	0.92	0.53	1.01	0.93	0.77	<0.01 **	0.61	<0.001 **	0.82	<0.05 **	2.07	0.13	1.27	0.15	1.72	<0.05 **
General Health
Excellent	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-	Ref	-
Very good	1.02	0.92	0.97	0.80	1.36	<0.05 **	1.28	<0.01 **	1.18	0.14	3.98	<0.01 **	1.64	<0.01 **	0.86	0.64
Good	0.76	0.25	0.92	0.64	1.34	<0.05 **	1.28	<0.05 **	1.24	0.11	2.37	<0.01 **	1.82	<0.001 **	0.73	0.34
Fair	0.88	0.69	0.57	<0.05	1.15	0.37	1.27	0.07	1.39	0.12	1.58	0.304	2.32	<0.05 **	0.66	0.35
Poor	0.75	0.39	0.76	0.59	0.95	0.88	0.77	0.44	0.92	0.79	1.82	0.105	1.67	0.243	1.07	0.91

** Statistically significant.

3.1. Female Sterilization

The odds of using this method increased with increasing age (aoRs; 25–29 = 3.98, 30–34 = 8.09, 35–39 = 12.50, 40–44 = 13.91; ref: 18–24) and having Medicaid insurance (aoR = 2.09, ref: private) and decreased for income levels of USD 50k or more (aoR = 0.51, ref: <15k), being unmarried (aoR = 0.5, ref: married), and having some other insurance coverage (aoR = 0.60).

3.2. Male Sterilization

The odds of using this method increased with increasing age (aoRs; 25–29 = 4.72, 30–34 = 8.71, 35–39 = 16.34, 40–44 = 25.01). The likelihood also increased with unemployment (aoR = 1.54, ref: employed) and increasing educational attainment (aoRs; some college = 2.29, college graduate = 2.19; ref: no high school diploma). Nevertheless, the odds of using the method decreased in certain racial groups (aoRs; non-Hispanic Black = 0.27, non-Hispanic other race = 0.32, non-Hispanic multiracial = 0.40, ref: non-Hispanic White), in unmarried individuals (aoR = 0.24), and in those with fair general health (aoR = 0.57, ref: excellent health).

3.3. IUD

The odds of using this method increased at certain levels of individual health (aoRs; very good = 1.36, good = 1.34) and decreased for those who were non-Hispanic Black (aoR = 0.47), unmarried (aoR = 0.78), self-pay/uninsured (aoR = 0.68), receiving other insurance coverage (aoR = 0.57), or for those without annual checkups (aoR = 0.77, ref: checkup over the past 12 months).

3.4. Pills, Rings, Patches, and Shots

The odds of using this method increased with educational attainment (aoRs; some college = 1.67, college graduate = 1.88), Medicaid insurance (aoR = 1.30), and certain health status (aoRs; very good = 1.28, good = 1.28). The odds of use dropped with increasing age (aoR; 30–34 = 0.71, 35–39 = 0.62, 40–44 = 0.51), among non-Hispanic Black respondents (aoR = 0.69), and for those without annual checkups (aoR = 0.61).

3.5. Condoms

The odds of using this method increased for those of Hispanic race (aoR = 1.81), college graduates (aoR = 1.51), and the Medicaid-insured (aoR = 1.45), and for certain health status (aoR; very good = 1.18, good = 1.24, fair = 1.39). The odds, however, decreased with age (aoRs; 25–29 = 0.72, 30–34 = 0.56, 35–39 = 0.58, 40–44 = 0.30), income (aoRs; USD 25 to <35k = 0.55, 35 to <50k = 0.60, 50k or more = 0.49), and certain insurance status (aoRs, self-pay/uninsured = 0.63, other = 0.65), and among those without annual checkups (aoR = 0.82).

3.6. Natural Family Planning

The odds of using this method increased with educational attainment (aoR = 4.38 some college) and general health (aoRs; very good = 3.98, good = 2.37), but the odds were decreased for the income groups USD 15 to <25k (aoR = 0.24) and 35 to <50k (aoR = 0.20) and unmarried respondents (aoR = 0.39).

3.7. Withdrawal

The odds of using this method increased for individuals with Medicaid insurance (aoR = 2.30) and those with certain general health status (aoRs; very good = 1.64, good = 1.82, fair = 2.32) and decreased for those of non-Hispanic other race (aoR = 0.52).

3.8. Women at Risk of Unintended Pregnancy

The odds of being at risk of unintended pregnancy increased for individuals of all non-White races (aoRs; non-Hispanic Black = 2.04; non-Hispanic other race = 2.78, non-Hispanic multiracial = 3.89, Hispanic = 2.32) and those without annual checkups (aoR = 1.72). Yet the probability was lower for those with income levels of USD 25 to <35k (aoR = 0.32) when compared to those with less than 15k (ref).

4. Discussion

We examined the use of contraceptive methods among women of reproductive age throughout the years 2019 to 2022. First, we observed that more than 70% of women used some type of contraceptive method in 2022. This finding is consistent with findings from the 2022 Family Planning Annual Report (FPAR) [22]. Yet this finding indicates a 16% rise in the use of contraception since 2019. This is noteworthy because, before 2019, the usage rate remained relatively stationary at around 65% over the years [12,13].

Second, we found similarities and dissimilarities in the use of individual methods compared to previous research. For instance, consistent with previous findings, we found that the use of IUDs, natural family planning, and withdrawal increased between the years of study. Contrary to previous studies, we found increases in the rate of the most effective methods, including sterilization (male and female). Further analysis of this change showed that the higher rate of non-Hispanic Black individuals using female sterilization was the driver of this change. Additional findings that contrast with previous studies showed large drops in the use of moderately effective methods including pills, rings, patches, and shots (mostly attributed to individuals with incomes less than USD 15k), as well as less effective methods including condoms (mostly attributed to non-Hispanic Black and multiracial female groups) [12,13]. These findings around race/ethnicity and increases in sterilization may be worrisome given that Black and Hispanic populations in the U.S. have historically experienced adverse treatment, including reproductive oppression and biomedical harm. For example, the Tuskegee study on Black American participants in Alabama that was initiated in 1932 resulted in the spread of syphilis infections to spouses, partners, and family members of participants; increased the severity of infections by withholding antibiotic treatment; and resulted in babies born with infection-related abnormalities, blindness, and other complications [23,24,25,26]. Members of those communities still experience a mistrust of biomedicine, have a fear of reproductive harm, and have refused beneficial medical interventions, such as novel coronavirus (COVID-19) vaccinations, because of this history. Indeed, research suggests significant rates of vaccine hesitancy and inequitable vaccine access in these communities during the COVID-19 pandemic [27]. Another recent study examining contraception preferences found that racial/ethnic minorities had a lower preference–use match, i.e., were less likely to receive their preferred method of reversible contraception (LARC and short-acting reversible contraception (SAC)) compared to non-racialized groups, and yet there was higher preference–use match when there was a more permanent contraception intervention. For example, Black individuals had higher matches with permanent methods and lower matches for LARC or SAC [28]. The overall contraceptive preference–use match in the latter study was 45.8%, i.e., less than half of respondents received the contraceptive method they preferred, which potentially signals an adverse outcome from post-Dobbs policy decisions.

Third, we found that the rate of females at risk of unintended pregnancy increased by about 4% since 2019, mostly driven by those with an income less than USD 15k. If this leads to more unwanted pregnancies, there will be a notable deviation from the trend observed over the past decade that showed unintended pregnancy rates dropping from 2010 to 2019 [20].

There are several possible explanations for the differences in our findings from those of previous studies. These differences could be attributed to factors such as data collection methods and surveys of different demographics [12,13,14,22,29]. Other factors contributing to these differences may include shifts in the use of a certain method attributed to individuals’ preferences or qualities such as the effectiveness, long-lastingness, and safety of a method [30]. Additionally, during the period of our study, some events occurred that may have caused disruptions in the accessibility and cost of contraception methods [1]. For example, some reports show that access to contraception methods was restricted in the years 2020–2021 because of the COVID-19 pandemic. According to these reports, access to methods that required prescriptions or visits to a healthcare provider, such as pills, rings, patches, and shots, were limited because visits were considered non-essential and were therefore delayed or canceled when they were provided in low-cost reproductive healthcare clinics that were forced to close. More restrictions were felt by people who lost their insurance coverage and, therefore, the ability to purchase contraceptives, or those who perceived it unsafe to leave their homes during quarantine [22,31,32]. Although one would argue these restrictions were imposed during the COVID-19 pandemic, studies have shown that pandemic-related disruptions have spurred shifts in health-related behaviors [33] and potentially influenced the observations made of increased use of less effective methods in the year 2022. Furthermore, attempts to restrict access to contraceptive methods following the Supreme Court’s decision on Dobbs in June 2022 have led to a counterintuitive increase in the use of more effective or even permanent contraception methods. Since Dobbs, some states with abortion bans in place have considered certain contraceptives—particularly IUDs and emergency contraceptive pills—abortifacients [34]. Conversely, in other states, such as those with disrupted abortion bans, the rate of patients seeking sterilization, IUDs, and implants increased [1]. This may explain our observation regarding increases in the use of female sterilization. Indeed, it is reported that there was significant confusion post-Dobbs about people’s access to contraceptive use, which changed the landscape of sexual and reproductive healthcare across the states. The 2022 BRFSS data were collected from January 2022 to February 2023, which includes samples both pre- and post-Dobbs [35]. Finally, shifts in the methods of contraception may have led to increasing rates of unintended pregnancy.

When we compared our analysis of individual characteristics associated with contraceptive use to the 2022 FPAR, some shared patterns were revealed. First, age is a significant factor in contraceptive choices. While older individuals favor the most effective or permanent options, such as sterilization, younger individuals tend to favor less effective methods like condoms. Second, racial disparities are evident in contraceptive practices, with non-Hispanic Black individuals exhibiting lower odds of using certain contraceptives relative to White individuals, which is consistent with emerging evidence [28]. Third, socioeconomic factors, such as income and insurance status, influence the use of contraceptive methods; the former is also highlighted in new research indicating poor preference–contraception match [28]. Furthermore, we found that uninsured individuals were less inclined to use a contraceptive method. This low contraceptive use is perhaps attributed to the loss of health insurance as suggested by the FPAR report [22]. Additional findings from our study show that access to healthcare, as gauged by factors such as routine checkups and health conditions, plays a significant role in contraceptive practices. Moreover, we found that non-White individuals and those without annual checkups were at higher risk of unintended pregnancy. This is consistent with the Centers for Disease Control and Prevention, which states that women who are of racial or ethnic minorities are at higher risk of unintended pregnancy [36].

Limitations

Our study comes with some limitations. First, the BRFSS is a self-report survey and is subject to recall bias and social desirability bias. These biases can influence the events that respondents recall during the interview process [37]. Second, the response rate was lower in 2022 compared to 2019, which may have introduced non-response bias, particularly in some states. Third, certain changes happened in the survey of 2019 vs. 2022; for example, some contraceptive methods in 2022 were combined. These changes would likely represent errors in population estimates. Despite these shortcomings, this study offers a fresh understanding of the trends among and characteristics of contraceptive users in 2022.

5. Conclusions

Our study revealed changes in women’s reproductive health patterns regarding contraceptive methods to prevent pregnancy. Our findings highlight the importance of understanding variations in contraceptive use to inform public policy to address reproductive health disparities, particularly among marginalized populations [38]. This study reveals the constant need for evaluating individuals’ preferences for contraception across time and female characteristics.