Prevalence and type of contraception use among US college students: A needed update

Abstract

Background

While rates of unintended pregnancy are declining among adolescents and young adults in the United States (US), rates remain higher than other industrialized nations and are associated with both educational and economic challenges. Studies examining young adult contraceptive practices are dated and limited in scope. Understanding current contraceptive use of young adults is critical to ensure intentional pregnancies.

Methods

We used the American College Health Association-National College Health Assessment III 2022–2023 national dataset to examine contraceptive use patterns among 30,568 sexually active 18- to 24-year-old college students at 4-year institutions. Differences based on students’ biological sex, race/ethnicity, year in school and number of sexual partners in the last 12 months were examined. Prevalence estimates with confidence intervals were calculated; chi-square tests were used to assess initial bivariate differences and t-tests were used to determine significant pairwise comparisons. Bonferroni correction set the significance level to p<.001219.

Results

Most sexually active college students were using contraception (87.6%); however, there were significant differences among students based on demographic characteristics. Black, Latinx, and multiracial students and students with more than one sexual partner in the last 12 months were less likely to use contraception (ps < 0.001). There were also differences in the types of single and dual contraceptive methods used among students based on demographics. Significant differences based on race/ethnicity occurred across all methods and combinations of methods. Results indicated less consistent patterns of differences for sex, year in school, and number of sexual partners for single and dual use.

Conclusions

This study provides a critical update on contraceptive use among US college students. The findings indicate which subgroups may be more at risk for an unintended pregnancy due to lower overall contraceptive use and use of methods that are less effective. Differences in race/ethnicity regarding contraceptive use continue to exist, and students with fewer years of education emerged as another essential group deserving attention. Improved awareness of methods and access to birth control are potential strategies to increase uptake. College health professionals and other clinical providers who work with US college students can use these findings to inform discussions with students who may need additional information about all available options.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-026-02314-z.

Plain language summary

Rates of unintended pregnancy among young adults in the United States (US) have been decreasing, but rates are still higher than other industrialized countries. Current information about contraceptive use among college students, a large segment of the young adult population nationally, is limited; this study fills that gap. Using a national dataset (2022–2023 American College Health Association-National College Health Assessment III), this study examines sexually active college students’ contraceptive use to prevent pregnancy the last time they had vaginal sex. Most students (87.6%) used some type of contraceptive method, but there were differences in using a method or not, what type of single method was used, and what type of dual methods were used among different groups of students. Patterns varied between different group of students, but some notable findings include: Students with one sexual partner in the last 12 months or those who were Asian or White were more likely to use contraception compared to students with more than one partner and other racial groups. Students in higher years of college were more likely to use more effective methods – like the IUD (intrauterine device), shot, patch or ring. Overall, the findings show that contraceptive use among US college students varies among different groups. Healthcare providers need to discuss the variety of available contraceptive options and engage in outreach to those with lower use to ensure students are aware of all methods and can select what is best for their individual circumstances.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-026-02314-z.

Background

The overall pregnancy rate in the United States (US) reached its lowest recorded level in 2020, driven primarily by a dramatic decline in pregnancies among individuals under the age of 25 [1]. Coinciding with this overall decrease was a decline in unintended pregnancies due to fewer teens and young adults (ages 15–24) becoming pregnant unintentionally [2]. This drop in pregnancy rates among adolescents and young adults can be attributed to both a decrease in sexual activity among teens [3, 4] and, for those who are sexually active, increased use of effective contraception [4]. At the same time, unintended pregnancy rates in the US continue to exceed rates of other Western countries [5] and differences between races/ethnicities also exist, with higher unintended pregnancy rates found among Black and Hispanic teens and young adults [6].

Given continuing interest in preventing unintended pregnancy and disparities, Szucs and colleagues [7] investigated US secondary school (9th -12th grade) students’ sexual behaviors using the national 2019 Youth Risk Behavior Survey. Their study found almost 90% of sexually active secondary students had used a contraceptive method at last sexual intercourse. Condoms were the primary method reported with over half of adolescents using condoms and 44% identifying condoms as the primary contraceptive method at last vaginal sex. Birth control pills were the next most frequently reported method (almost one-quarter of students). Differences related to race/ethnicity mirrored rates of unintended pregnancy nationwide with non-Hispanic Black and Hispanic secondary school students more likely to report not using a method at last sex act.

While Szucs et al. [7] provides insight into the US secondary school population, a similar recent analysis does not exist for young adults. Within the young adult population, a critical and unique subgroup is college students [8]. College students at 4-year institutions constitute 30% of the total 18–24-year-old US population [9], and the transition to college often includes moving away from home and establishing independence, including being responsible for one’s own health care [10]. Within this context, sexual and reproductive health can affect one’s success in college as an unintended pregnancy is connected to a lower GPA [11] and college drop out [12] which is linked to lower employment earnings [13]. While the number of unintended pregnancies in individuals under age 24 has declined [14] (specific data on college students is not available), mistimed and unwanted pregnancies are still an issue for this population [14]. Addressing unintended pregnancy among college students – specifically increasing contraception access and use – has been identified as a strategy to improve academic success [15] as access to contraception has been causally linked to increased college degree completion and better economic outcomes for US women [16].

Previous studies regarding college students’ contraceptive use are dated (e.g. Walsh-Buhi & Helmy [17] with data from 2014) or have a narrow focus (e.g. differences between cisgender women and sexual minority women assigned female at birth [18]). To address this gap, the current study uses a recent (2022-23) national dataset and models the work of Szucs and colleagues [7] to investigate contraceptive use at last act of vaginal sex to prevent pregnancy among US college students. The specific aims of the study are (1) to present overall contraceptive use rates for a national sample of US college students and (2) to examine differences among demographic groups, similar to Szucs et al. [7]: sex, race/ethnicity, year in school, and number of sexual partners.

Methods

Data source

This study used data from the American College Health Association-National College Health Assessment III (ACHA-NCHA III) to examine contraceptive use among US undergraduate students. This online comprehensive national college health survey is administered by the American College Health Association (ACHA). Institutions of higher education self-select to participate in the ACHA-NCHA III in the fall or spring of each academic year. Participating schools receive their own institution’s dataset; data from all participating institutions in a single semester that surveyed a random sample of students or census are aggregated into a national reference group dataset; data from schools using a convenience sample are not included. More information on the ACHA-NCHA III development and instrumentation is available elsewhere [19].

The current study uses aggregated data from the Fall 2022 and Spring 2023 ACHA-NCHA III administrations. The original dataset included 111,798 student participants from 176 institutions. Each participating school received approval by their own Institutional Review Board (IRB) and student respondents provided informed consent prior to participating. Data were made available for secondary analysis by ACHA [20]. Indiana University’s IRB deemed the study non-human subjects research as it uses secondary de-identified data.

Participants

For the purposes of this study, the sample was limited to undergraduate students at 4-year institutions between 18 and 24 years old. Graduate students were excluded in order to compare the results as much as possible to the secondary school results of Szucs et al. [7]. Because previous research suggests that students attending community colleges (2-year institutions) have lower rates of contraceptive use than 4-year college students [21], these students (n = 4430) were removed to avoid confounding the results. The 18 to 24 age range was selected to be somewhat consistent with age ranges used for reporting pregnancy and birth data by US federal agencies (i.e., 15–19 years old, 20–24 years old); however, any respondents under 18 were removed by ACHA before distributing the dataset, hence the final age range of 18 to 24 years. Almost half of the students (47.6%) had engaged in vaginal sex in the previous 12 months and those who had not (n = 35,770) were removed from the analyses. Students who reported the following were also removed from the dataset: being intersex (n = 24), being infertile (n = 30), using sterilization for pregnancy prevention (n = 89), or not trying to prevent pregnancy (n = 230). Once the inclusion criteria had been applied, the final participant group consisted of 30,568 students. There was an even distribution across years in school; however, the sample was primarily female (75.6%, n = 23,110) and White (62.3% n = 19,053). Most students had only one sexual partner in the last 12 months (65.8%, n = 20,110) and were in a relationship or partnered/married (65.2%, n = 19,940). Table 1 contains all demographic information.

Table 1.

Demographic Characteristics

Demographic	% (n)
Biological Sex
Female	75.6% (23,110)
Male	24.4% (7,458)
Year in School
1st	23.8% (7,286)
2nd	23.1% (7,057)
3rd	26.2% (7,999)
4th	22.9% (6,995)
5th or more	4.0% (1,231)
Race/Ethnicity*
Asian	9.1% (2,789)
Black	3.7% (1,131)
Latinx	9.2% (2,821)
White	62.3% (19,053)
Multiracial	13.8% (4,215)
Number of Sexual Partners in Last 12 Months
1	65.8% (20,110)
2+	34.2% (10,458)
Relationship Status
Not in a relationship	34.7% (10,598)
In a relationship	62.2% (19,027)
Married/Partnered	3.0% (913)

*Race/ethnicity values do not total 100% because “other” responses are not reported (i.e., American Indian/Native Alaskan, Middle Eastern/North Africa/other Arab, Native Hawaiian/Other Pacific Islander Native, or Other)

Measures

The variables in the present study were matched to those used by Szucs et al. [7] to the degree possible given the differences in survey instruments. There were two primary outcomes of interest. The first asked “Did you or your partner use any method to prevent pregnancy the last time you had vaginal intercourse (penis in vagina)?” Response options were yes; no, did not want to prevent pregnancy; no, did not use any method; and don’t know. As previously mentioned, respondents who did not want to prevent pregnancy were eliminated from the analyses. For the analyses, students who did not use a method or did not know if a method was used were combined into a “no method” group. These groups were combined as neither were able to view additional questions related to birth control and the small percentage of students indicating they did not know (1.2%) could be considered at similar risk for pregnancy as those who were not using a method.

The second outcome of interest was the method used for pregnancy prevention. Students who indicated they had used a pregnancy prevention method were asked to select all methods they used at last act of vaginal sex. Options included birth control pills (monthly or extended cycle); birth control shots; birth control implants; birth control patch; the ring; emergency contraception (“morning after pill” or “Plan B”); intrauterine device (IUD); external condom (sometimes called “male” condom); internal condom (sometimes called “female” condom); diaphragm or cervical cap; contraceptive sponge; withdrawal; fertility awareness (calendar, mucous, and basal body temperature); sterilization (for example: hysterectomy, tubes tied, or vasectomy); don’t know; other method. Dichotomous variables were computed from the individual methods to measure contraceptive use more comprehensively. Specifically, seven (yes/no) items -were created to examine demographic differences among those using a single method of contraception at last vaginal sex: (1) IUD or implant; (2) shot, patch or ring; (3) birth control pills; (4) condom; (5) withdrawal or other method (cap, diaphragm, sponge, or fertility awareness method); (6) a high or moderately effective method defined as IUD, implant, shot, patch, ring or birth control pills; and (7) no method. These variable categories mimic those used by Szucs et al. [7].

We also assessed students’ use of more than one contraceptive as previous research has shown that about 20% of US adults used more than one method at last act of sex (i.e., dual methods) [22] and using more than one method can further reduce the risk of an unintended pregnancy. We created four dichotomous variables to examine dual method use: condoms and a high/moderately effective method; condoms and birth control pills; withdrawal and condoms; and withdrawal and a high/moderately effective method. These categories were determined based on several factors: (1) Szucs et al. [7] examined condom use combined with a high/moderately effective method. We followed their definition for high/moderately effective methods as described previously. (2) About one in five unmarried men in the US report using withdrawal as their sole method of contraception [23]. Withdrawal is also often used as a secondary contraceptive method [24, 25], and if used consistently and correctly, it could be an effective method due to low sperm levels in pre-ejaculatory fluid [26]. (3) Other researchers have reported that college women have a preference for the combined use of condoms and birth control pills [27].

Demographic variables included in the analyses were sex assigned at birth (male/female), undergraduate year in school (1st, 2nd, 3rd, 4th, 5th or more), and race/ethnicity. Race/ethnicity response options included multiracial, Asian, Black, Latinx, White, American Indian/Native Alaskan, Middle Eastern/North Africa/other Arab, Native Hawaiian/Other Pacific Islander Native, or Other. Students could select more than one race/ethnicity; those who did were recoded as multiracial. Students reported their number of sexual partners in the last 12 months (recoded into a dichotomous variable of one (1) partner or 2 + partners) and their relationship status (not in a relationship, in a relationship, or married partnered).

Analysis

Frequencies were examined for the use of a specific contraceptive method, the use of a single contraceptive method, and dual contraceptive method use. For single contraceptive method use and dual use, contraceptive use was examined by demographic characteristics (biological sex, race/ethnicity, year in school, number of sex partners), similar to Szucs et al. [7]. For racial/ethnic differences, Asian, Black, Latinx, White and multiracial were examined; other categories were not included in race comparisons due to small sample sizes. Because there was considerable overlap between students’ number of sex partners and their relationship status, we opted to only examine number of sexual partners, which was also consistent with Szucs et al. [7].

Prevalence estimates and confidence intervals were calculated for each outcome (no use of contraception, single method use, and dual method use). Cross-tabulations and chi-square statistics were used to examine differences by demographic characteristics. For those analyses with significant overall differences, t-tests were used to identify pairwise differences between demographic groups. Because of the large sample size and multiple analyses, Bonferroni correction (0.05/41) was applied with p-values < 0.001219 considered significant. All analyses were conducted in SPSS (version 28.0.0).

Results

Contraceptive use to prevent pregnancy among this national sample of sexually active US college students was relatively high (87.6%), with only 12.4% reporting no method used during last act of vaginal sex. The most commonly used methods were external condoms (48.9%), birth control pills (38.8%), and withdrawal (20.5%). See Table 2 for all frequencies and Fig. 1 for select prevalence rates.

Table 2.

Contraceptive Use at Last Act of Vaginal Sex*

	n	% of full sample (N = 30,568)	% of those who used any method (N = 26,775)
Birth control pills	11,852	38.8	44.3
Birth control shots	487	1.6	1.8
Birth control implants	1,790	5.9	6.7
Birth control patch	271	0.9	1.0
The vaginal ring	502	1.6	1.9
Emergency contraceptive pill	1,810	5.9	6.8
Intrauterine Device (IUD)	3,541	11.6	13.2
Male (external) condom	14,948	48.9	55.8
Female (internal) condom	23	0.1	0.1
Diaphragm or cervical cap	6	0.02	0.02
Contraceptive sponge	8	0.03	0.03
Withdrawal	6,267	20.5	23.4
Fertility Awareness Methods	1,555	5.1	5.8

*Percentages total more than 100% because respondents could mark more than one response

Fig. 1.

Prevalence of select contraceptives used at last vaginal sex among sexually active college students. High/moderately effective method defined as IUD, implant, shot, patch, ring or birth control pills

Male and female students reported not using any contraceptive method (e.g. “no method”) almost equally (12.4% vs. 12.3%, respectively) with no significant difference. There were, however, significant differences between males and females regarding the type of contraceptive used for both single method and dual method behaviors. For single methods, females reported higher use of IUD/Implant (11.1% vs. 9.1%), withdrawal/other methods (2.5% vs. 1.6%), and high/moderately effective method (28.1% vs. 25.0%); whereas, males reported higher use of condoms (23.4% vs. 16.1%). Frequencies and confidence intervals for students using a single method and no method are reported in Table 3. Prevalence rates for students using a high/moderately effective method are visually represented in Fig. 2. Graphs for Table 3 data are included as supplemental figures. There were also significant differences by sex regarding dual method use; females were more likely to report using withdrawal and condoms (9.7% vs. 8.3%) and withdrawal and high/moderately effective method (7.2% vs. 4.5%), and males were more likely to report using condoms and birth control pills compared to females (15.6% vs. 12.9%). Table 4 contains frequencies and confidence intervals for rates of students using dual methods.

Table 3.

Single contraceptive use prevalence at last vaginal sex among sexually active* college students by demographics

Demographic	No method		IUD or implant		Shot, patch, or ring		Birth control pills		Condom		Withdrawal or other method †
	% (CI)	p-value¶	% (CI)	p-value¶	% (CI)	p-value¶	% (CI)	p-value¶	% (CI)	p-value¶	% (CI)	p-value¶
Total	12.4 (11.8-13.0)		10.6 (10.0-11.2)		1.9 (1.6-2.1)		14.9 (14.2-15.5)		17.9 (17.2-18.6)		2.3 (2.0-2.6)
Sex		0.27		< 0.001		0.05		0.16		< 0.001		< 0.001
Female	12.3 (11.6-13.0)		11.1 (10.5-11.8)		2.0 (1.7-2.3)		15.0 (14.3-15.8)		16.1 (15.3-16.8)		2.5 (2.2-2.8)
Male	12.4 (11.8-13.0)		9.1 (8.0-10.1)		1.6 (1.2-2.1)		14.4 (13.0-15.7)		23.4 (21.9-25.0)		1.6 (1.1-2.1)
Year in School		0.005		< 0.001		0.003		< 0.001		< 0.001		< 0.001
1st	12.5 (11.2-13.7)		6.9**,††,§§,¶¶ (6.0-7.9)		1.8 (1.3-2.3)		12.2††,§§,¶¶ (10.9-13.4)		21.6**,††,§§,¶¶ (20.1-23.2)		1.5**,††,§§ (1.0-1.9)
2nd	11.8 (10.6-13.1)		10.2**,†† (9.0-11.3)		1.5 (1.0-1.9)		14.1§§ (12.8-15.5)		18.4**,††,§§ (16.9-19.9)		2.1**,†† (1.5-2.6)
3rd	12.4 (11.2-13.6)		11.6** (10.4-12.7)		2.1 (1.6-2.7)		16.1 (14.8-17.4)		16.4 (15.1-17.8)		2.5** (1.9-3.1)
4th	12.4 (11.1-13.7)		12.9 (11.6-14.2)		2.0 (1.5-2.5)		16.9 (15.4-18.3)		15.8 (14.4-17.2)		2.7 (2.1-3.3)
5th or more	15.8 (12.4-19.1)		16.2 (12.8-19.6)		2.8 (1.3-4.4)		15.7 (12.3-19.0)		13.3 (10.2-16.5)		4.6 (2.6-6.5)
Race/Ethnicity		< 0.001		< 0.001		0.00118		< 0.001		< 0.001		< 0.001
Asian	12.2§§§,¶¶¶ (10.2-14.2)		6.0***,†††,§§§ (4.5-7.4)		1.2¶¶¶ (0.5-1.9)		13.1††† (11.0-15.1)		35.2***,†††,§§§,¶¶¶ (32.3-38.1)		2.3 (1.4-3.2)
Black	23.6***,††† (19.5-27.7)		7.6††† (5.1-10.1)		3.2 (1.5-4.9)		12.6 (9.4-15.8)		18.1††† (14.4-21.8)		4.2††† (2.3-6.2)
Latinx	19.1***,††† (16.7-21.5)		10.1 (8.3-11.9)		1.9 (1.1-2.7)		13.4††† (11.3-15.4)		22.6***,††† (20.0-25.1)		3.3††† (2.2-4.4)
White	10.6*** (9.9-11.3)		11.7 (10.9-12.4)		1.9 (1.6-2.2)		15.8*** (14.9-16.7)		14.2*** (13.3-15.0)		1.9 (1.6-2.2)
Multiracial	12.4 (10.8-14.1)		10.3 (8.8-11.8)		2.0 (1.3-2.7)		13.7 (12.0-15.5)		19.0 (17.1-21.0)		2.8 (1.9-3.6)
Partner Number		< 0.001		0.17		< 0.001		< 0.001		0.01		0.31
1	11.4 (10.7-12.1)		10.8 (10.1-11.5)		2.1 (1.8-2.4)		16.0 (15.2–16.9)		18.3 (17.4-19.2)		2.3 (2.0-2.7)
2+	14.4 (13.3-15.5)		10.3 (9.3-11.2)		1.5 (1.1-1.9)		12.6 (11.6–13.7)		17.1 (15.9-18.3)		2.2 (1.7-2.6)

Abbreviations: CI confidence interval, IUD intrauterine device

*Defined as having had vaginal sex in the last 12 months

^†Other methods refer to cap, diaphragm, sponge or fertility awareness methods (FAM)

^¶Significance defined as p<.001219

**Significantly different than 5th or higher year in school

^††Significantly different than 4th year in school

^§§Significantly different than 3rd year in school

^¶¶Significantly different than 2nd year in school

*** Significantly different than multiracial students

^†††Significantly different than White students

^§§§Significantly different than Latinx students

^¶¶¶Significantly different than Black students

Fig. 2.

Use of a single moderate or highly effective contraception (i.e., IUD, implant, shot, patch, ring or birth control pills) prevalence at last vaginal sex among sexually active college students by demographics. Significance defined as p < .001219, shown as * for dichotomous variables and indicated by letter for multi-category variables

Table 4.

Dual contraceptive use prevalence at last vaginal sex among sexually active* college students by demographics

Demographic	Condoms AND High or moderately effective method†		Withdrawal AND Condoms		Withdrawal AND High or moderately effective method†			Condoms AND Birth control pills
	% (CI)	p-value§	% (CI)	p-value§	% (CI)		p-value§	% (CI)	p-value§
Total	25.3 (24.5-26.1)		9.4 (8.8-9.9)		6.5 (6.1-7.0)			13.6 (13.0-14.2)
Sex		0.94		< 0.001			< 0.001		< 0.001
Female	25.3 (24.4-26.2)		9.7 (9.1-10.3)		7.2 (6.6-7.7)			12.9 (12.2-13.7)
Male	25.3 (23.7-27.0)		8.3 (7.3-9.3)		4.5 (3.7-5.3)			15.6 (14.3-17.0)
Year in School		< 0.001		< 0.001			< 0.001		< 0.001
1st	28.2¶,**,†† (26.5-30.0)		11.9¶,**,††,§§ (10.6-13.1)		5.1**,††,§§ (4.3-5.9)			15.3¶,**,†† (13.9-16.6)
2nd	27.3¶,**,†† (25.5-29.0)		9.4 (8.3-10.6)		6.4 (5.4-7.3)			15.2¶,**,†† (13.8-16.6)
3rd	24.1¶ (22.6-25.7)		8.2 (7.2-9.2)		7.1 (6.2-8.0)			13.0¶ (11.8-14.2)
4th	22.8 (21.2-24.4)		8.4 (7.3-9.5)		7.8¶ (6.7-8.8)			11.7 (10.5-13.0)
5th or more	18.9 (15.2-22.5)		7.2 (4.8-9.5)		5.3 (3.2-7.4)			9.5 (6.8-12.2)
Race/Ethnicity		< 0.001		< 0.001			< 0.001		< 0.001
Asian	16.9¶¶, *** (14.6-19.2)		7.8*** (6.2-9.5)		3.3¶¶,*** (2.2-4.4)			10.4¶¶,*** (8.6-12.3)
Black	18.0¶¶,*** (14.3-21.8)		7.0*** (4.5-9.4)		4.0*** (2.1-5.9)			9.3¶¶,*** (6.5-12.1)
Latinx	15.7¶¶,*** (13.5-17.9)		7.8*** (6.2-9.5)		3.5¶¶,*** (2.4-4.6)			8.4¶¶,*** (6.7-10.1)
White	28.6¶¶ (27.5-29.6)		10.1 (9.4-10.8)		7.8¶¶ (7.2–8.5)			15.3¶¶ (14.4-16.1)
Multiracial	25.2 (23.0-27.3)		8.8 (7.4-10.2)		5.9 (4.7-7.1)			13.2 (11.6-14.9)
Partner Number		< 0.001		< 0.001			0.63		0.11
1	24.0 (23.0-24.9)		8.7 (8.0-9.3)		6.6 (6.0-7.1)			13.4 (12.6-14.2)
2+	27.9 (26.5-29.3)		10.7 (9.8-11.7)		6.4 (5.7-7.2)			14.0 (12.9-15.4)

Abbreviations CI=confidence interval; IUD=intrauterine device

*Defined as having had vaginal sex in the last 12 months

^† Defined as IUD, implant, shot, patch, ring or birth control pills

^§ Significance defined as p<.001219

^¶ Significantly different than 5th or higher year in school

** Significantly different than 4th year in school

^†† Significantly different than 3rd year in school

^§§ Significantly different than 2nd year in school

^¶¶ Significantly different than multiracial students

*** Significantly different than White students

Regarding year in school, there were no significant differences among students who used a method and those who did not use any method of pregnancy prevention. However, there were significant differences for year in school for all single method contraceptive use, except for those using the shot, patch or ring. Trends differed depending on the method. For example, rates of IUD/implant significantly increased as year in school increased and condom use decreased with first-year students more likely to use condoms than all other years, and second-year students more likely to use condoms than third, fourth, or fifth-year students. Other trends among single methods were increased use of withdrawal/other methods and high/moderately effective methods of birth control for students in higher years of school. Regarding dual methods, there were significant differences for all four categories, with a decreasing trend by year in school for three of the four -- condom and high/moderately effective method, withdrawal and condoms, and condoms and birth control pills. While the dual use of withdrawal and high/moderately effective method was significant for year in school, there was no clear pattern of differences with first years having lower rates than second, third, and fourth years, and fourth years significantly higher than fifth years. At the same time, there were no significant differences between third- and fourth-year students, with the only significant difference between fourth- and fifth-year students reported previously.

There were significant differences for all methods regarding race/ethnicity: not using a method, all single methods, and all dual methods. Black (23.6%) and Latinx (19.1%) students were more likely to indicate not using a method than Asian (12.2%), White (10.6%) and multiracial students (12.4%). Regarding those using a single contraceptive method, there were several significant differences, but no specific pattern of use based on race/ethnicity. For use of a high/moderately effective method, White students reported a significantly higher rate (29.4%) than all other groups (multiracial 26.1%, Latinx 25.4%, Black 23.3%, Asian 20.2%). White students also reported the highest rate of birth control pill use (15.8%). Their use rate was statistically significantly higher than the rate reported by multiracial (13.7%), Latinx (13.4%), and Asian students (13.1%) but not Black students (12.6%). White students also reported the highest rate of IUD/implant use (11.7%), but this was only significantly different than rates for Asian (6.0%) and Black (7.6%) students. Asian students reported a significantly higher rate of condom use (35.2%) than all other race/ethnicities (multiracial 19.0%, Latinx 22.6%, Black 18.1%, White 14.2%). There were no significant differences between Black and Latinx students for use of any of the single contraceptive methods.

For students using dual methods, White students reported higher and significantly different rates from all other races/ethnicities for all methods except one: there was no significant difference between White and multiracial students for dual use of withdrawal and condoms. For example, 28.6% of White students reported using condoms and high/moderately effective method compared to 25.2% of multiracial, 18.0% of Black, 16.9% of Asian and 15.7% of Latinx students, with Asian, Black and Latinx students significantly different from White and multiracial students. Similar results were found for condoms and birth control pills (White 15.3%, multiracial 13.2%, Asian 10.4%, Black 9.3% and Latinx 8.4%) with Asian, Black and Latinx students reporting significantly lower rates than White and multiracial students. For withdrawal and high/moderately effective method, Asian (3.3%) and Latinx (3.5%) students had significantly lower rates of use than White (7.8%) and multiracial students (5.9%), but Black students’ (4.0%) rates were only significantly lower than White students. Similar to respondents using a single contraceptive method, there were no significant differences between Black and Latinx students.

There were significant differences related to contraceptive use based on the number of sexual partners in the last 12 months as well. Students with two or more partners in the past year were statistically less likely to use a contraceptive method (85.6%) compared to students with only one partner (88.6%). Students who used a single contraceptive method and had one partner were more likely to use the shot/ring/patch (2.1%), birth control pills (16.0%), and a high/moderately effective method (28.9%) than students with two or more partners (1.5%, 12.6%, and 24.4%, respectively). Students with two or more partners had significantly higher rates of dual contraceptive use for condoms and high/moderately effective method (27.9%) and condoms and withdrawal (10.7%) compared to respondents with one partner in the last 12 months (24.0% and 8.7%, respectively).

Discussion

This study aimed to provide an updated understanding of contraceptive use among US college students modeling a similar study done with US secondary school students. Overall, most students (87.6%) used contraception to prevent pregnancy during their last act of vaginal sex; however, a sizeable group of sexually active students are at risk for an unintended pregnancy. This rate is similar to that found by Szucs et al. [7] in secondary school students -- 89.3% (95% CI 88%-91.2%) -- indicating that use of contraception does not dramatically change once students enter college. Like Szucs et al. [7] we also found that condoms and birth control pills were the most commonly used methods. The current study also exposed a potential change in rates regarding type of contraception used by college students. Looking at analysis from 2014 ACHA-NCHA data [17], it appears that there has been some shift towards long-acting reversible contraception (LARC) and away from condoms and pills. In the current study, IUD and implant use were higher in the current study at 11.6% and 5.9% compared to 4.9% and 3.4% in 2014. In contrast, condom use was 49.0% and birth control pill use was 38.8% compared to 66.5% and 49.0% in 2014, respectively. Exact comparisons cannot be made as the previous study only looked at sexually active women and included students from community colleges whereas the current study’s prevalence rates include responses from males and females. At the same time, the increased use of more effective methods is still striking and is consistent with other research. Some studies (e.g. Mitchell et al. [28]) have shown increased use of LARC in the months following the overturning of Roe v Wade by the U.S. Supreme Court (which eliminated federal protection for abortion access). The increased desire to prevent an unintended pregnancy could be an influencing factor given these data were collected in the 2022-23 academic year.

The current study also found significant differences in contraceptive use and/or choice of method for pregnancy prevention among college students based on sex, year in school, race/ethnicity and number of partners. Females were more likely to report use of an IUD/implant and withdrawal or other method while males were more likely to report use of a condom. Given that females may be using these methods without informing a partner, this difference is not surprising as males may simply not realize that a method was being used. Previous research has shown females’ disclosure of contraceptive use is based on the quality of the relationship and partner’s anticipated response [29] which were not measured in the current study. College males are more likely to acquire and apply condoms than females [30] which may explain the current study’s finding of males reporting higher use of condoms than females. At the same time, the current study’s findings regarding withdrawal differ from previous research that that found no differences between males and females [31]. However, Fu and colleagues’ study [31] worded withdrawal items differently (i.e. “ejaculation outside the vagina”) in an attempt to more accurately determine withdrawal frequency rates among adults since reasons beyond pregnancy prevention such as pleasure or cleanliness could be reasons for individuals to use withdrawal. It is possible that this difference also affected reporting rates in the current study. An additional consideration regarding male-female differences for all responses is a potential misreading of the question by males. While the item specifies “you or your partner,” it is possible that males may have glossed over the detail about partner and just answered for themselves. At the same time there was no difference in males and females reporting “no method” of contraception so if this misreading occurred, it may have been among individuals using more than one method.

We also found that students in their earlier years of college were less likely to report using a high/moderately effective method. While the actual rates are different, the increased use in later years of college is similar to the pattern of increase between ninth and twelfth graders found by Szucs et al. [7]. Likewise, general US rates show the highest rate of birth control pill and LARC use among women 20- to 24-years old compared to all other age groups including 15- to 19-year-olds [32]. Older students in both high school and college may have more autonomy and confidence in their sexual decision making. Additionally, many college students can utilize sexual and reproductive health services on campus [33] which can increase access to more effective birth control methods. However, there are concerns that students may not be aware of these services [15, 34] and experience other barriers like cost [35] and lack of health insurance [35]. At the same time, fifth-year students were more likely to report using withdrawal or other methods than first-year, second-year and third-year students. The potential reasons for this are unclear and warrant further examination.

Similar to Szucs et al.’s [7] findings, the current study identified racial/ethnic differences, with Black and Latinx students less likely to report using a contraceptive method and less likely to report using a high/moderately effective method. Given that Black and Latinx young adults are more at-risk for unintended pregnancy [6], this finding is concerning but not surprising. Formalized education on contraceptives increases comprehensive knowledge [36] and can help individuals select methods that are more likely to be effective for them [37]. Given the similar trends between high school and college and overall lower usage rates of high/moderately effective methods, current sexuality education in the US appears insufficient to assist young adults in decision-making regarding pregnancy prevention. Some states do not require sexuality education and of those that do, few require medically accurate contraceptive education [38]. Other research has documented declining rates of individuals receiving contraceptive education in their teens [39]. A global review of systematic reviews found that a combination of educational and contraceptive promoting interventions lowered the unintended pregnancy rate for adolescents [40]. Given the lack of sexuality education described previously and limited contraception knowledge college students may have [41], college health professionals could use the successful interventions with adolescents as a guide to address unintended pregnancy on their campuses. Given the differences in contraceptive use among Black and Latinx students, these efforts should ideally incorporate cultural humility to develop individual-centered education and clinical experiences specifically inclusive of Black and Latinx students [42]. This approach should be utilized in all contexts, whether it be focused discussions during clinical visits with providers or health education provision in one-on-one, extra-curricular, or classroom settings.

Interestingly, students with only one partner were more likely to report higher rates of using any method than those with two or more partners (88.6% vs. 85.6%) and were more likely to report using a high/moderately effective method among those using a single method. However, when examining dual method use, those with two or more partners reported higher rates for two categories: high/moderately effective and condoms and withdrawal and condoms. While the survey item specifically asked about the use of contraception for pregnancy prevention, this increased condom use among students with more than one partner may indicate students’ awareness of STI (sexually transmitted infection) risk. It is also possible that condoms are simply more accessible than other methods given the variety of places that US college students commonly access condoms (e.g. off-campus drug stores, off-campus grocery stores, friends, campus health centers, campus events [30]). Likewise, other studies have shown that higher commitment to a partner is associated with riskier sexual activity (e.g., Smith and South [43], VanderDrift et al. [44]). Overall, slightly over half of those reporting a contraceptive method used condoms, indicating potential for improvement in condom usage for those who may also be at risk for an STI. Health promotion efforts in addition to discussions with clinicians can facilitate this increase. Fu et al. [45] found that healthcare provider conversations about condom use with females using LARC were associated with increased use of both LARC and condoms. College health centers and other health care providers working with college students need to continue reminding patients about potential STI risk and the benefits of condoms even when students are using high/moderately effective methods to prevent pregnancy.

In the current study, about one in five students reported withdrawal as a pregnancy prevention method. As previously mentioned, Fu and colleagues [31] indicated underreporting of withdrawal rates when participants were also asked about “ejaculation outside the vagina.” For example, they found about 17% of 14- to 24-year-olds reported withdrawal, but when asked about ejaculation outside the vagina/anus, the rate jumped to 33% -- a difference too large to be solely caused by male-male sex. Given the high rates of withdrawal as part of dual method use in the current study, we recommend more research examining withdrawal practices, how students perceive withdrawal’s effectiveness for pregnancy prevention, and how to help students practice withdrawal to its highest level of effectiveness.

As with all research, this study is not without limitations. The current study examined US college students at 4-year institutions whose experiences and institutions may be different than other parts of the world, especially in those with lower healthcare access or alternatively, those with universal healthcare. Additionally, while a national survey, the ACHA-NCHA III is not a representative sample though only institutions that surveyed a random sample of students or census are included in this national dataset. Similarly, the sample was restricted to undergraduate students at 4-year institutions and those 18- to 24-years old which limits generalization to community college students, older undergraduate students, graduate students, and 18- to 24-year-olds not in currently in college. At the same time, with one-third of US 18- to 24-year-olds enrolled in college [9], this is a critical population in their own right. Another limitation is our use of sex assigned at birth; this determination was made to best understand students’ risk in experiencing a potential pregnancy and related prevention behaviors. This decision modeled the Szucs et al. [7] study and was also made in order to not duplicate Reynolds and Charlton’s work [18] exploring contraceptive use differences between college students who were cisgender women and gender minorities who were assigned female at birth. Due to sample size limitations, we did not include some races/ethnicities in the analyses examining racial/ethnic differences in contraceptive use. Modeling Szucs et al., [7] we combined some contraception methods into groups which limits the examination of these methods individually (e.g. combining IUD and implant; withdrawal with fertility awareness methods, cervical cap, diaphragm and sponge). Finally, the survey item asked students about the method(s) used for pregnancy prevention, and it is possible that some marked methods being used for non-contraceptive benefits.

Future research is needed in several areas. This study focuses on college students at 4-year institutions and while they are a substantial portion of US young adults, there could be value in comparing young adults attending college versus those not attending especially given that college students may have access to sexual health education and services on campus [33] which may affect knowledge about and access to contraception. Similarly, examination of contraceptive practices of graduate students and more current research on contraceptive practices of community college students is warranted to understand the needs of all US college students. Comparisons of contraceptive use of college students across nations to examine any differences may also be useful. Additionally, researchers should consider qualitative study designs to better understand the reasons for these demographic differences. Finally, examination of the impact of the changing legal landscape regarding sexual and reproductive health services and students’ ability to access contraception is needed. While access to many different contraceptives is currently available across the US, there is some evidence that access to birth control pills has been impacted due to clinic closures in abortion restricted states [46]. Uncertainty about continued access with the changing political landscape and new and increasing restrictions related to sexual and reproductive health services warrants additional future research.

Conclusion

Modeling research about US secondary school students’ contraceptive use, this study provides a needed updated examination of US college students’ pregnancy prevention practices. The results can guide efforts by college health professionals and other educators and clinicians working with college students to better support students who may be less likely to use contraceptives or use methods with lower effectiveness rates. Continued examination of contraceptive use among US young adults and specifically college students will be needed in the future, especially if there are more systemic changes in access to sexual and reproductive health services and family planning methods.

Abbreviations

US

United States

ACHA-NCHA III

American College Health Association-National College Health Assessment III

ACHA

American College Health Association

IRB

Institutional Review Board

IUD

Intrauterine Device

LARC

Long-acting Reversible Contraception

STI

Sexually Transmitted Infection

CI

Confidence Interval

Authors’ contributions

AL and SO jointly conceptualized the study and finalized methods. SO conducted analyses and wrote initial article drafts. All authors made revisions and approved the final manuscript.

Funding

Not Applicable.

Data availability

The data that support the findings of this study are available from the American College Health Association (ACHA). Restrictions apply to the availability of the data used in this study based on our data use agreement with ACHA and so are not publicly available.

Declarations

Ethics approval and consent to participate

Individual institutions participating in the ACHA-NCHA must obtain IRB approval for survey administration on their campus. Additionally, Indiana University’s IRB reviewed the proposed study and deemed it non-human subjects research since it is deidentified secondary analysis.

Consent for publication

Not applicable.

Competing interests

SO declares no competing interests. AL declares no competing financial interest and declares a volunteer position as the Chair of the ACHA-NCHA Advisory Committee.