A Century of Contraceptive Use in America:Lessons from the Past, Challenges of the Future

Jacqueline E. Darroch, Ph.D.Seattle, WA

Society of Family PlanningOctober 1, 2009Los Angeles, CA

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1800 1820 1840 1860 1880 1900 1920 1940 1960 1980 2000

Tot

al f

erti

lity

rat

e

American women’s average number of children fellfrom 7 in 1800 to 3.6 in 1900 and 2.1 in 2000.

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The risk of dying from pregnancy and childbirth fell from almost 1 in 1,000 in 1900 to 1 in 100,000.

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0 5 10 15 20 25 30

1890

1995

Age

The timing and character of women’s early reproductive lives has changed.

Menarche 14.7

Menarche 12.6

Marriage 21.9

First birth 23.7

First birth 26.0

Marriage 25.1

Intercourse 17.4

Median ageat key events

Skuy, 1995.

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First Half of the 1900s:Condom, Douche and Withdrawal

• 1978 retrospective survey of white, ever married women born 1901-1910, who were in their prime reproductive ages in the 1920s and 1930

• 71% of women had used a contraceptive; another 16% had used douche for hygiene; 11% never used either.

• 35% of women used a contraceptive before their first birth.

• 4% had used contraceptive sterilization, but 9% had been surgically sterilized by age 35 and 23%, by age 45.

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Women born 1901-1910 used a variety of contraceptive methods, especially condom, douche and withdrawal.

0 20 40 60 80 100

Vaginal cap or IUD

Lactation

Contraceptive sterilization

Abstinence

Infrequent Intercourse

Suppository or tablets

Jelly or cream

Diaphragm

Rhythm

Withdrawal

Contraceptive douche

Condom

% of women who ever used each method

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Mid-1900s:Condom, Diaphragm and Periodic Abstinence

• 1955 Growth of American Families surveyed white married women 18-39

• 70% had used a contraceptive; 34% before their first pregnancy

• Family planning clinics in some areas had started to offer diaphragms, spermicides and condoms

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Contraceptive users in 1955 had the same choice of methods as earlier; most common were diaphragm, condom and rhythm.

0 20 40 60 80 100

Vaginal cap or IUD

Lactation

Contraceptive sterilization

Abstinence

Infrequent Intercourse

Suppository or tables

Jelly or cream

Diaphragm

Rhythm

Withdrawal

Contraceptive douche

Condom

% of current contraceptive users

11bestcontraceptionmethods.combestcontraceptionmethods.com

1960s:New methods – pill, IUD, office-based sterilization and more…..

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1955 1965 1975 1985 1995

Vasectomy

TubLig

Injection

Implant

IUD

Pill

PerAbst

Diaphragm

Condom

Withdrawal

Douche

Other reversible

Condom, diaphragm or periodic abstinence were the most commonly used methods in 1955.*

*White married women aged 18-39;

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1955 1965 1975 1985 1995

Vasectomy

TubLig

Injection

Implant

IUD

Pill

PerAbst

Diaphragm

Condom

Withdrawal

Douche

Other reversible

Method use changed dramatically in the 1960s, with advent of the pill, IUD and office-based sterilization.

1955: White married women aged 18-39;other years: all married women 15-44.

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1955 1965 1975 1985 1995

Vasectomy

TubLig

Injection

Implant

IUD

Pill

PerAbst

Diaphragm

Condom

Withdrawal

Douche

Other reversible

Pill and IUD use dropped after the mid-1970s with concerns about health impacts; sterilization rose steeply.

1955: White married women aged 18-39;other years: all married women 15-44.

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1955 1965 1975 1985 1995

Vasectomy

TubLig

Injection

Implant

IUD

Pill

PerAbst

Diaphragm

Condom

Withdrawal

Douche

Other reversible

Starting in the 1980s, more users chose condoms, the pill and new long-acting methods.

1955: White married women aged 18-39;other years: all married women 15-44.

2002

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1982 2002

Vasectomy

TubLig

Injection

Implant

IUD

Pill

PerAbst

Diaphragm

Condom

Withdrawal

Other reversible

Most never-married contraceptors rely on the pill. In the mid-1990s, condom use peaked and long-acting method use rose.

1982-1995:All never-married women 15-44.2002: Non-cohabiting never-married women, 15-44.

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A Century of Change

• Social and sexual behavior

• Health risks of pregnancy

• Methods available

• Patterns of method use

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Condom25%

Withdrawal7%

PerAbst21%

Other female10%

Douche7%

TubLig6%

Diaphragm24%

Men’s participation accounted for 53% of contraceptive use in Men’s participation accounted for 53% of contraceptive use in 1955, but for 32% in 2002.1955, but for 32% in 2002.

Vasectomy9%

Condom18%

Withdrawal4%

PerAbst1%

Other female1%

TubLig27%

Pill31%

Long-Acting9%

1955 20021955 2002 Married white women 18-39 All women 15-44Married white women 18-39 All women 15-44

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Condom25%

Withdrawal7%

PerAbst21%

Other female10%

Douche7%

TubLig6%

Diaphragm24%

Episodic methods were 94% of use in 1955, but 24% in 2002; Episodic methods were 94% of use in 1955, but 24% in 2002; long-acting methods rose from 6% to 45% of total use.long-acting methods rose from 6% to 45% of total use.

Vasectomy9%

Condom18%

Withdrawal4%

PerAbst1%

Other female1%

TubLig27%

Pill31%

Long-Acting9%

1955 20021955 2002 Married white women 18-39 All women 15-44Married white women 18-39 All women 15-44

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Condom25%

Withdrawal7%

PerAbst21%

Other female10%

Douche7%

TubLig6%

Diaphragm24%

Access to clinical providers was required for 30% of method Access to clinical providers was required for 30% of method use in 1955, but 76% of use in 2002.use in 1955, but 76% of use in 2002.

Vasectomy9%

Condom18%

Withdrawal4%

PerAbst1%

Other female1%

TubLig27%

Long-Acting9%

Pill31%

1955 20021955 2002 Married white women 18-39 All women 15-44Married white women 18-39 All women 15-44

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Lessons from the past, Challenges of the Future

• Balancing expectations and reality of contraceptive methods

• Assuring access to a wide range of methods, including higher-cost and long-acting methods

• Focus on both use and use-effectiveness, especially for episodic and user-controlled methods

• Negotiating control of method use: user—partner—provider

• Technology affects method choice and use.

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