Among those US women who are in the stages of their lives when they are most likely to be at risk of HIV and other sexually transmitted infections (STI), most contraceptive use involves hormonal methods. Only a small minority of sexually active women and their partners are using condoms, which help prevent HIV.
Information about the fertility regulation practices of HIV-infected and at-risk women in the United States is important to judge the magnitudes and characteristics of groups for whom there may be special concern and to understand how similar or different their choices are from those of other women. The key source of nationally representative information on sexual and reproductive behavior and on patterns and trends in contraceptive use and non-use among US women is the National Survey of Family Growth (NSFG). The NSFG is a personal household survey, fielded periodically by the National Center for Health Statistics. The most recent available data are from 1995, when 10,847 women aged 15–44 years were surveyed.
Although the NSFG has long included a rich set of questions about contraceptive use, questions about multiple sexual partnerships and other behaviors that increase people's risk of HIV have been asked only recently, and respondents’ HIV status is not ascertained. Although limited, these data provide some indication on a national basis of the demographics of women's sexual behaviors that are indicative of a heightened risk of acquiring STI, including HIV. They provide an indication of women's exposure to hormonal contraception, as well as to the use of condoms.
Potential Exposure to Sexually Transmitted HIV
In 1995, an estimated 34% of US women aged 15–44 years who had had sex with a man in the past 12 months were exposed to multiple partners in the past year, because they themselves and/or their partners had had more than one sexual partner during the year. The true level is probably even higher because this estimate comes from self-reported survey data. Many women and men with multiple partners over a year's time probably see themselves as monogamous, that is within their current relationship, so-called ‘serial monogamy’.
Women most likely to be exposed to multiple partners are younger women, unmarried women, those who are poor and African-American women, and often these characteristics overlap. Over half of all sexually active women under the age of 25 years are estimated to have had two or more sexual partners over a year's time, or to have had a partner who has had sex with other women over that time period: 61% of sexually active women aged 15–17 years, 67% of those aged 18–19 years, and 53% of women aged 20–24 years. Among older sexually active women, 22–35% of those aged 25–39 years and 15% of 40–44-year-olds were not in mutually monogamous relationships. Some 64% of unmarried women were exposed to multiple partners over a year's time, as were 10% of married women. Rates of exposure were approximately twice as high among women under 100% of poverty (over 40%) than women at and above 200% of poverty (over 20%), and rates among African-American women were approximately double the levels among Hispanic women and 2.5 times the rates of non-Hispanic white women. To a large extent, these differences reflect the fact that poorer women and African-American women are much more likely than others to be unmarried. Whereas being African-American is an independent predictor of exposure to multiple partnerships, differences by income status appear not to be independent, but to reflect the impacts of age, union status, education, region of the country and race/ethnicity, which vary by poverty status1.
Contraceptive Choices over Time
Contraceptive methods used by women and men in the United States have varied over the years, reflecting both changing contraceptive technology and changing times. The proportion of married contraceptive users relying on condoms decreased from 26% in 1955 to 11% in 1976, then rose to 18% by 19952–4. More limited data for never-married contraceptive users show an even steeper increase in recent years, from 12% in 1982 to 30% in 19955.
Hormonal contraceptive methods first became available with FDA approval of OCs in 1960. By 1973, 36% of married contraceptive users were using OC. This proportion dropped to a low of 20% in 1982 and rose slightly to 23% in 1995 for those who were using OC or other hormonal method, primarily 3-month injections. Hormonal method use has consistently been higher among never-married women, accounting for over half of all method use. The level rose slightly from 53% in 1982 to 59% in 1988, and then dropped back to 52% in 1995, as condom use increased.
Most women in the United States use OC at some time in their reproductive lives. Of the women aged 15–44 years in 1995, 80% of those aged 25 years and older had used OC4.
Current Patterns of Method Use
Among all women aged 15–44 years in 1995 who were sexually active (in the 3 months before being surveyed in the NSFG), 24% were using hormonal methods: 19% were using OCs only, usually combined estrogen–progestin formulations; 3% were using long-acting progestin-only methods, primarily the 3-month injection; and another 2% were using these methods and condoms as well. Some 19% were using condoms: 2% of women used condoms and hormonal methods; 13% used condoms alone; and 4% used condoms and other methods. In addition, 8% of sexually active women were using other reversible methods, 29% were relying on contraceptive sterilization, 7% were using no method even though they were at risk of unintended pregnancy, and 15% were using no method and were not at risk of unintended pregnancy because they were pregnant, postpartum, trying to become pregnant or were infertile.
The contraceptive methods chosen by US couples vary widely according to whether or not they want to have children in the future, because high proportions of women and men turn to contraceptive sterilization once they have had all the children they want to have. This can be at a fairly early age: by the age of 30.9 years, half of US women want no (more) children and by age of 33.2 years, half of men intend to have no more6,7.
As a result, method use patterns differ widely according to women's ages. The use of hormonal methods increases from 32% of all sexually active women aged 15–17 years to 47% of those aged 20–24 years, and then drops steadily to 5% of women aged 40–45 years. Never-married women are most likely to rely on hormonal methods: 40% of never-married sexually active women who are not living with a partner use hormonal methods, compared with 34% of those who are cohabiting, 21% of formerly married women and 18% of married women. However, married women who intend to have children in the future are almost as likely as unmarried cohabiting women to use hormonal methods (32%), whereas only 11% of women intending to have no more children do so.
Patterns of method use vary little by poverty status and they do not differ widely across racial and ethnic groups, except that hormonal method use is somewhat lower and condom use higher among non-Hispanic women who are neither white nor African-American. Women who were in multiple partnerships over the past year and those whose partners had other sexual partners are more likely to be using hormonal methods (26–31%) than are women reporting mutually monogamous relationships (22%). Among all women using hormonal contraceptive methods, 28% report that they and/or their partner have had other sexual partners in the past year.
As noted above, fewer women rely on condoms than use hormonal methods, and not very many women using hormonal methods also report condom use. Overlapping use is most common among never-married women. One in five of those using hormonal methods have partners who also use condoms, accounting for 8% of all sexually active never-married women. Condom use alone or together with other reversible methods is also most common among never-married women, accounting for 26% of them4,8.
Since their introduction into the United States more than four decades ago, hormonal methods have been part of most women's contraceptive experience. Women are most likely to use hormonal methods when they are unmarried and when they are young, largely because women and men in the United States generally turn to permanent contraceptive sterilization once they have had all the children they want. As a result, not only is hormonal method use common, but the life stages in which use is highest coincide with times when short-term and multiple sexual partnerships, and the potential exposure to HIV and other STI, are most likely.
Research on which this analysis is based was partly funded by the National Institute of Child Health and Human Development, grant HD31646 and by grant FPR000057 from the Office of Population Affairs of the US Department of Health and Human Services.
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2. Forrest JD. Contraceptive use in the United States: past, present and future. In: Severy LJ, editor. Advances in population: psychosocial perspectives, Vol.2. London and Bristol, PA: Jessica Kingsley Publishers; 1994. pp. 29–48.
3. The Alan Guttmacher Institute tabulations of ‘Public use data tape documentation: National Survey of Family Growth, Cycle IV, 1988’. Hyattsville, MD: National Center for Health Statistics; 1990.
4. The Alan Guttmacher Institute tabulations of ‘Public use data tape documentation: National Survey of Family Growth, Cycle V, 1995’. Hyattsville, MD: National Center for Health Statistics; 1997.
5. Bachrach CA. Contraceptive practice among American women, 1973–1982. Fam Plann Perspect 1984; 16:253–259, tabulations from the 1988 NSFG; tabulations from the 1995 NSFG.
6. The Alan Guttmacher Institute. For women: Fulfilling the promise: public policy and U.S. family planning clinics. New York The Alan Guttmacher Institute; 2000.
7. The Alan Guttmacher Institute. For men: In their own right: addressing the sexual and reproductive health needs of American men. New York The Alan Guttmacher Institute; 2002.
8. Bankole AB, Darroch JE, Singh S. Determinants of trends in condom use in the United States, 1988–1995. Fam Plann Perspect 1999; 31:264–271.