Beyond use: lessons on contraceptive inequity from the National Survey of Family Growth

Although readers of F&S Reports may spend more time focused on helping people achieve pregnancy, their work fits under the overarching goal of helping patients achieve their reproductive goals.

The reproductive justice framework, developed by Black women activists in 1994 and advanced nationally by the SisterSong Women of Color Reproductive Justice Collective, holds that all people have the human right to bodily autonomy: to choose to have children, not to have children, and to parent their children in safe and sustainable communities. The framework expands beyond the assumption of fertility and family planning as an individual choice or a right, and emphasizes the socioeconomic conditions and structural barriers that influence if, when, and how individuals achieve their reproductive goals, which can fluctuate across the lifespan (1). For readers of Fertility & Sterility Reports, this framework is less a departure from clinical practice than an extension of it.

The article by Zolna et al. (2) examines contraceptive use and preferences among reproductive-aged adults using nationally representative data collected from 2022 to 2023. For more than five decades, the CDC’s National Center for Health Statistics has conducted the National Survey of Family Growth (NSFG) (3), aimed at providing nationally representative data on pregnancy, contraceptive use, and infertility, among other aspects of reproductive health. Beyond simply tabulating reproductive outcomes, the NSFG captures the individual intentions, preferences, and life circumstances that shape them. Although the original form of the NSFG in 1973 studied the reproductive behaviors of married women, it has grown to fully reflect the diversity of American families—individuals regardless of marital status, men, and a wider age range (15–49 years).

Early rounds of the NSFG relied on in-person interviews, with more sensitive questions answered through a private, self-administered component, and achieved response rates near 70%. The most recent 2022–2023 round utilized a new contractor and evolved to accommodate a web-based option, leading its response rate to fall and its representation to shift toward a more advantaged and less comparable sample than in prior rounds. Even so, the NSFG remains a vital resource for population-level estimates that have informed federal and state health programs, translated into public health priorities, and generated thousands of scientific publications. As a result, studies leveraging this resource offer a uniquely valuable window into the reproductive experiences of the US population.

Historically, researchers focused family planning metrics on whether contraception is used and, if so, what methods. However, the use of a contraceptive method alone does not signal whether that person’s reproductive goals are being met. A patient might be placed on hormonal contraception to manage heavy menstrual bleeding, while actually desiring to conceive (4). A patient might have received a depot medroxyprogesterone acetate (DMPA) injection, thinking they were postponing a planned pregnancy for 3 months without fully understanding that return to fertility after the last injection can be delayed by several months. The more meaningful question for researchers goes beyond simply uptake and continuation of a method; Zolna et al. (2) begin the conversation of addressing whether individuals are able to use their preferred method, if they choose to use a method at all. This shift from examining behavior alone emphasizes the importance of the alignment between contraceptive preferences and the political and socioeconomic realities that patients encounter. Crucially, the investigators move beyond the single most-effective method that prior analyses tracked and reframe a familiar, surface-level reassurance: a high contraceptive prevalence no longer means most people are content, only that most are using some method of contraception. Whether they are using the method they would choose, and the factors that stand in the way of alignment, becomes the more revealing question.

In 2022–2023, 57% of reproductive-aged women, 42.8 million, reported using contraception for any reason, and 22% of users relied on more than one method. Notably, the oral contraceptive pill (23%) and the condom (21%) have now overtaken female permanent methods (20%), historically the most commonly used method, as the methods women most often report using. Yet use alone tells an incomplete story: 13% of contraceptive users (excluding those relying only on female permanent methods) reported they would prefer a different method, and 31% of nonusers said they would start one, if cost were not a worry, together, an estimated 10 million women of reproductive age. Among those using a single method, unfulfilled preferences were highest for coital-dependent methods (23%) and lowest for long-acting methods such as the intrauterine device (IUD) (7%).

These findings reveal a deeper inequity. The IUD, whose users were least likely to report an unfulfilled preference, was concentrated among women in more advantaged groups: older, non-Hispanic white, and college-educated. Withdrawal, by contrast, drew the highest level of unfulfilled preferences although it costs nothing, and it was used disproportionately by younger and Black women. Individuals may not be choosing withdrawal—the free, default method—so much as being left with it, because the method they would prefer stays out of financial or practical reach. That a cost-free method draws the highest unfulfilled preference is the clearest sign of inequity that a single contraceptive prevalence statistic conceals.

A myriad of factors contribute to a patient’s inability to access reproductive healthcare consistent with their reproductive goals. Structural barriers such as out-of-pocket costs and lapses in insurance coverage might preclude access. Further, some doctors may be unwilling or unable to provide a method of choice despite statewide initiatives supporting same-day contraceptive access (5). Although the single NSFG item examining barriers to the fulfilment of contraceptive preferences asked specifically about cost, the estimates by Zolna et al. (2) likely understate the true gap between the methods women use and those they would choose.

Barriers to arriving at concordance between the methods patients prefer and the methods they use are not static. The COVID-19 pandemic and the Dobbs decision have each reshaped whether and how people access contraception. Federal cuts to reproductive health funding, alongside efforts to dismantle the very datasets, including the NSFG, that allow us to see these gaps, threaten to widen them. Zolna et al. (2) make this widening gap more visible such that policymakers do not become complacent that most women use contraception, but that they become heartened to close the distance between the method a woman uses and the one she chooses.

In line with a reproductive justice lens, specialists in reproductive endocrinology increasingly recognize that their patients experience a spectrum of reproductive issues beyond infertility alone. Many patients spend decades of their lives actively trying to avoid pregnancy before their unanticipated later needs for infertility treatment. Similarly, some patients undergoing infertility treatments might eventually encounter spontaneous conception of an unintended pregnancy, thereby requiring contraceptive counseling once achieving their desired family size. As our patients’ reproductive lives will oscillate between phases of preventing pregnancy, actively pursuing pregnancy, and ambivalence, we view providing contraception and fertility care as complementary, thereby warranting continued updates on how we meet our patients’ contraceptive needs and preferences.

CRediT Authorship Contribution Statement

Marit Pearlman Shapiro: Writing – original draft, Writing – review & editing. Brian T. Nguyen: Writing – original draft, Writing – review & editing.

Declaration of Interests

B.T.N. provides research advisory services for Sumitomo Pharma America Inc and Natural Cycles. M.P.S. has nothing to disclose.