Continuing social disparities despite upward trends in sexual and reproductive health service use among young women in the United States

Abstract

Background

Building upon previous work describing declining rates and socioeconomic disparities in sexual and reproductive health (SRH) service use among young women in the United States, we re-examined patterns and determinants of SRH service use in 2006–2010.

Study Design

We used the latest data from the National Survey of Family Growth to evaluate SRH service use including contraceptive, sexually transmitted infection (STI), and other gynecological exam services among 3,780 women ages 15–24 years. We compared proportions of service use across survey years and employed multiple logistic regression to estimate the influence of time and women’s sociodemographic characteristics on the likelihood of SRH service use.

Results

The proportion of women using SRH services increased from 50% (2006–2007) to 54% (2007–2008) and 57% (2008–2010) (all year ORs 1.4, p-values<0.03). Among sexually experienced women, the proportions using SRH and contraceptive services were unchanged while STI service use increased from 22% (2006–2007) to 33% (2008–2009) (OR 1.7, CI 1.1–2.4, p=0.009). Differentials in service use existed across sociodemographic groups, largely with lower proportions of service use among women of social disadvantage.

Conclusions

Our results suggest a reversal of negative trends but continuing social disparities in young women’s use of SRH services in the United States.

1. Introduction

Between 2002 and 2006, negative trends and disparities in sexual and reproductive health (SRH) outcomes were noted among young women in the United States. Disproportionate rising teen pregnancy and sexually transmitted infection (STI) rates and stalled contraceptive use and abortion rates contrasted with previously improving outcomes prior to 2002 [1–8].We recently described corresponding declining trends in young women’s use of SRH services, including contraceptive services, between 2002 and 2006 [9]. We also described disparities in service use that negatively impacted young women of social disadvantage [10], which also occurred in the context of inequalities in SRH outcomes for poor and racial/ethnic minority women in the U.S [2–8].

Building upon this work, we analyzed more recent trends and determinants of use of SRH services among adolescent and young adult women in the United States using updated data from 2006 through 2010.

2. Materials and methods

Data were drawn from the U.S. population-based SRH survey, The National Survey of Family Growth (NSFG), which collects information on family life, marriage and divorce, pregnancy, infertility, use of contraception and health. Data were collected continuously via inperson household interviews with 12,279 U.S. women ages 15 to 44 years from 2006 through 2010. Black and Hispanic women and young women were oversampled. The response rate was 77%. Additional information about the design and sampling of the NSFG can be found at http://cdc.govnchs/nsfg.htm [11].

We focused on adolescent and young adult women (15–24 years) (n=4,360); pregnant women (n=580) were excluded. Our final sample included 3,780 young women. The Institutional Review Board of Princeton University approved this study.

We have described our methods and measurement of SRH service use within the NSFG elsewhere [9, 10]. Briefly, women were asked about receipt of SRH services from a medical provider within the 12 months preceding the survey and how many visits were made. Women were also asked the reason for services, which could include contraceptive services (contraceptive method provision, check-up, counseling, emergency contraceptive (EC) provision and counseling), STI testing/treatment services and other gynecological services (Pap smear, pelvic exam). We considered women to have used any recent SRH services if they responded that they had made one or more visits to a provider within the last year.

We used a 4-point indicator of the time frame in which the survey was administered: year 1=June 2006–June 2007; year 2=July 2007–June 2008; year 3=July 2008–June 2009; year 4=July 2009–June 2010.

For analysis of data, we described and compared estimates (weighted proportions) of SRH service use overall, by survey year and by type of service using descriptive and bivariate statistics (unadjusted Χ² tests). We examined SRH service use for all young women and then among sexually experienced women only. We performed multivariable logistic regression modeling to estimate the influence of survey year on the likelihood of using SRH services while adjusting for age, sexual experience and other potential sociodemographic and reproductive history confounders. A description of our theoretical basis for selection of sociodemographic covariates can also be found elsewhere [9, 10]. Variables were considered for inclusion in regression models if their p-value in univariate models was 0.25 or less. In final reduced multivariate regression models, we retained only those covariates that were significantly associated with the outcome (p<0.05). For variables that appeared to be collinear (e.g., many of the reproductive history variables), we chose variables with the strongest effect to retain in final models. Finally, we tested for trends over time and examined potential disparate changes in service use across sociodemographic groups using interaction terms for survey year. We used survey weights and the SVY Stata 11.0 commands in all analyses to account for the complex, stratified sampling design of the survey (Stata Corporation, College Station, TX).

3. Results

Demographic, social and reproductive characteristics of the sample are described in Table 1. Briefly, the mean age of the sample was 19 years, with 54% adolescents (15–19 years) and 46% young adults (20–24 years). White race/ethnicity accounted for over half of young women (62%); 15% identified as Black; 18% identified as Hispanic; 7% identified as other. Forty-three percent were still in secondary school while 36% reported having had at least some college education. Over half the sample (53%) was below 200% of the federal poverty level; 25% was uninsured at some point during the previous year. Nearly two-thirds of young women (60%) had experienced vaginal sexual intercourse, with 16% reporting history of pregnancy and 16% reporting diagnosis of a gynecological problem.

Table 1.

Characteristics of the young women in the United States, 2006–2010

N = 3,780	n	%
Survey year    June 2006–June 2007    July 2007–June 2008    July 2008–June 2009    July 2009–June 2010	961 810 1,022 987	26 24 27 23
Age group    15–17 years    18–19 years    20–24 years	1,259 854 1,667	31 23 46
Race/ethnicity    Hispanic    White    Black    Other	822 1,969 748 241	18 62 15 7
Education level    < High school    High school or GED    Any college    Still in school	347 493 1,236 1,704	8 13 36 43
Residence    Rural    Urban    Suburban	552 1,617 1,611	19 37 44
Born inside U.S. Born outside U.S.	3,395 385	91 9
≥ 200% federal poverty level < 200% federal poverty level	1,633 2,147	47 53
Employment    Employed    Unemployed    In school    Other	1,858 232 995 695	53 6 26 15
Fully insured last year Uninsured any time last year	2,748 979	75 25
Frequency of religious service attendance    ≥ Weekly    < Weekly    Never	1,120 1,677 980	31 45 25
Mother’s education level    < High school    High school diploma or GED    > High school	657 1,114 1,989	15 28 57
Childhood family situation    Lived with two parents (intact)    Other situations (disrupted)	1,947 1,833	56 44
Ever cohabitated or married    Yes    No	970 2,810	26 74
Sexual intercourse experience    Ever had sexual intercourse    Never had sexual intercourse	2,332 1,448	60 40
Number of sexual partners last year    None    One    Two or more	1,635 1,474 671	44 39 17
Pregnancy history    Ever pregnant    Never pregnant	3,066 714	84 16
History of gynecological problems    No gynecological diagnosis    Diagnosed with gynecological problems	3,202 578	84 16

Results are presented as frequencies with weighted percentages. Totals may not add to 100% due to rounding or nonresponses.

Overall, 55% of young women between 2006–2010 used SRH services including contraceptive (45%) and STI (18%) services. Among sexually experienced women, 77% used SRH services including contraceptive (64%) and STI (29%) services.

In 2006–2007 (survey year 1), half of young women reported SRH service use (50%), with the proportion of service use increasing to 54% in 2007–2008 (year 2) and then to 57% in 2008–2010 (years 3 and 4) (Table 2). Compared to 2006–2007, women in all other subsequent year periods were 1.4 times as likely to use services (all ORs 1.4, p-values<0.03). Among sexually experienced women, proportions of SRH service use were stable across years (74% in 2006–2007 to 78% in all other year periods, p-values>0.14). The proportions of women using contraceptive services use ranged from 61% in 2007–2008 to 67% in 2008–2009 but were also statistically similar across time (p-values>0.20) (Table 3). However, there was an increase in STI service use from 22% in 2006–2007 to 31% in 2007–2008 (OR 1.6, CI 1.1–2.4, p=0.02) and to 33% in 2008–2009 (OR 1.7, CI 1.1–2.4, p=0.009) (Table 3).

Table 2.

Sexual and reproductive health service use among young women in the United States, overall and by sexual experience, 2006–2010

	All women ages 15–24 years (n=3,780)		Sexually experienced women (n=2,332)
	% who used SRH services (n=2,081, 55%)	Odds of SRH service use OR (95%CI) p	% who used SRH services (n=1,777, 77%)	Odds of SRH service use OR (95%CI) p
Year (continuous)		1.1 (1.0–1.2) 0.04		1.0 (0.9–1.2) 0.49
Survey year    June 2006–June 2007    July 2007–June 2008    July 2008–June 2009    July 2009–June 2010	50 54 57 57	1 1.4 (1.0–2.0) 0.03 1.4 (1.1–1.9) 0.01 1.4 (1.0–1.9) 0.03	74 78 78 78	1 1.4 (0.9–2.1) 0.14 1.3 (0.9–1.8) 0.16 1.2 (0.8–1.8) 0.42
Age group    15–17 years    18–19 years    20–24 years	29 54 72	1 1.7 (1.2–2.4) 0.002 2.8 (1.9–4.2)<0.001	61 76 81	1 2.2 (1.3–3.7) 0.002 3.2 (1.9–5.4) <0.001
Race/ethnicity    Hispanic    White    Black    Other	46 57 58 49	1 1.3 (0.9–1.9) 0.13 1.7 (1.1–2.5) 0.01 0.9 (0.5–1.7) 0.76	70 79 79 70	1 1.2 (0.8–1.9) 0.31 1.5 (1.0–2.5) 0.08 0.7 (0.3–1.7) 0.44
Education level    <High school    High school or GED    Any college    Still in school	59 68 69 37	1 1.4 (0.8–2.6) 0.29 2.4 (1.4–4.2) 0.003 2.2 (1.2–3.9) 0.008	68 73 85 71	1 1.3 (0.7–2.4) 0.45 2.5 (1.3–4.6) 0.005 1.8 (1.3–4.6) 0.09
Residence    Rural    Urban    Suburban	60 55 51	1 0.8 (0.6–1.2) 0.36 0.9 (0.7–1.3) 0.70	77 78 76	1 1.0 (0.7–1.5) 0.90 0.9 (0.6–1.4) 0.71
Born inside U.S. Born outside U.S.	55 46	1 0.8 (0.6–1.2) 0.30	78 68	1 0.8 (0.5–1.4) 0.45
≥200% federal poverty level <200% federal poverty level	56 53	1 1.0 (0.8–1.3) 0.88	79 76	1 1.1 (0.8–1.5) 0.49
Employment    Employed    Unemployed    In school    Other	63 67 39 46	1 1.2 (0.7–2.0) 0.58 1.1 (0.8–1.5) 0.69 1.1 (0.8–1.6) 0.63	79 78 77 70	1 1.2 (0.7–2.0) 0.50 1.3 (0.9–1.8) 0.20 1.1 (0.7–1.6) 0.81
Fully insured last year Uninsured any time last year	60 54	1 0.6 (0.4–0.8) <0.001	80 71	1 0.5 (0.4–0.7) <0.001
Frequency of religious service attendance    ≥Weekly    <Weekly    Never	38 61 62	1 1.4 (1.1–1.8) 0.02 1.3 (1.0–1.9) 0.09	72 80 76	1 1.3 (0.9–1.9) 0.16 1.1 (0.7–1.8) 0.54
Mother’s education level    <High school    High school diploma or GED    >High school	51 57 54	1 1.2 (0.8–1.7) 0.45 1.0 (0.7–1.5) 0.96	68 78 79	1 1.1 (0.7–1.7) 0.65 1.1 (0.7–1.6) 0.78
Disrupted childhood family situation Intact childhood family situation	58 52	1 0.8 (0.7–1.0) 0.08	75 79	1 1.0 (0.8–1.3) 0.88
Never had sexual intercourse Ever had sexual intercourse	21 77	1 2.7 (1.6–4.6) <0.001
Number of sexual partners last year    None    One    Two or more	24 79 80	1 4.6 (2.7–7.8) <0.001 5.0 (2.9–8.7) <0.001	47 79 80	1 4.9 (2.9–8.2) <0.001 5.5 (3.2–9.6) <0.001
No gynecological diagnosis Diagnosed with gynecological problems	50 76	1 3.6 (2.5–5.2) <0.001	75 87	1 2.5 (1.5–4.0) <0.001

SRH = sexual and reproductive health. Results are presented as odds ratios (OR), 95% confidence intervals (CI) and p-values (P) from multiple logistic regression models among sexually experienced women. Models also controlling for age at menarche.

Table 3.

Contraceptive and sexually transmitted infection service use among sexually experienced young women in the United States, 2006–2010

	Contraceptive services		Sexually transmitted infection services
Sexually experienced women ages 15 –24 years (n=2,332)	% who used services (n=1,457, 64%)	Odds of service use OR (95% CI) p	% who used services (n=700, 29%)	Odds of service use OR (95% CI) p
Year (continuous)		1.0 (0.9–1.2) 0.60		1.1 (1.0–1.2) 0.22
Survey year    June 2006–June 2007    July 2007–June 2008    July 2008–June 2009    July 2009–July 2010	62 61 67 63	1 1.1 (0.8–1.6) 0.38 1.3 (0.9–1.8) 0.20 1.1 (0.8–1.6) 0.57	22 31 33 28	1 1.6 (1.1–2.4) 0.02 1.7 (1.1–2.4) 0.009 1.3 (0.9–1.8) 0.19
Age group    15–17 years    18–19 years    20–24 years	53 68 64	1 1.8 (1.1–2.9) 0.02 1.5 (0.9–2.6) 0.11	28 26 30	1 1.1 (0.6–1.8) 0.87 1.7 (1.0–3.2) 0.07
Race/ethnicity    Hispanic    White    Black    Other	55 70 50 58	1 1.4 (1.1–2.3) 0.03 0.8 (0.6–1.3) 0.41 0.8 (0.4–1.6) 0.58	26 28 36 25	1 0.9 (0.6–1.3) 0.63 1.3 (0.9–1.9) 0.65 1.0 (0.6–1.8) 0.94
Education level    <High school    High school or GED    Any college    Still in school	47 58 71 62	1 1.5 (0.9–2.5) 0.14 2.5 (1.5–4.0) 0.001 1.9 (1.1–3.3) 0.02	31 27 29 29	1 0.8 (0.5–1.3) 0.33 0.9 (0.6–1.4) 0.64 1.1 (0.6–1.8) 0.82
Residence    Rural    Urban    Suburban	69 61 63	1 0.7 (0.5–1.0) 0.07 0.7 (0.5–1.0) 0.03	24 32 28	1 1.5 (1.1–2.2) 0.02 1.4 (0.9–2.1) 0.14
Born inside U.S. Born outside U.S.	64 55	1 0.8 (0.5–1.4) 0.45	30 20	1 0.6 (0.4–1.1) 0.08
≥200% federal poverty level <200% federal poverty level	65 62	1 1.1 (0.8–1.5) 0.49	27 30	1 1.1 (0.8–1.5) 0.50
Employment    Employed    Unemployed    In school    Other	66 62 68 49	1 1.2 (0.7–2.1) 0.50 1.3 (0.9–1.8) 0.20 1.1 (0.7–1.6) 0.81	28 32 31 30	1 1.2 (0.7–2.1) 0.46 1.3 (0.8–2.0) 0.26 1.1 (0.7–1.6) 0.69
Fully insured last year Uninsured any time last year	69 55	1 0.5 (0.4–0.7) <0.001	29 27	1 0.8 (0.6–1.1) 0.26
Frequency of religious service attendance    ≥Weekly    <Weekly    Never	54 65 67	1 1.3 (0.9–1.9) 0.16 1.1 (0.7–1.8) 0.54	25 28 33	1 1.1 (0.8–1.6) 0.56 1.4 (1.0–2.1) 0.08
Mother’s education level    <High school    High school diploma or GED    >High school	53 62 68	1 1.1 (0.7–1.7) 0.65 1.1 (0.7–1.6) 0.78	26 28 30	1 1.1 (0.7–1.8) 0.68 1.3 (0.8–2.0) 0.29
Disrupted childhood family situation Intact childhood family situation	59 67	1 0.9 (0.7–1.3) 0.88	24 33	1 0.7 (0.5–0.9) 0.005
Number of sexual partners last year    None    One    Two or more	29 66 66	1 4.9 (2.9–8.2) <0.001 5.5 (3.2–9.6) <0.001	15 26 40	1 1.9 (1.2–3.2) 0.01 3.5 (2.0–6.1) <0.001
No gynecological diagnosis Diagnosed with gynecological problems	62 72	1 2.5 (1.5–4.0) <0.001	28 30	1 1.0 (0.7–1.4) 0.85

STI = sexually transmitted infection. Results are presented as odds ratios (OR), 95% confidence intervals (CI) and p-values (p) from multiple logistic regression models among sexually experienced women. Models also controlling for age at menarche.

SRH service use varied by women’s sociodemographic characteristics (Tables 2 and 3). Black women, older, college-educated and insured women, those with less frequent religious service participation, sexual experience, more sexual partners and gynecological problems had greater odds of using SRH services compared to their counterparts. Greater odds of contraceptive service use (among sexually experienced women) were noted among White women, older, college-educated, rural-residing and insured women, those with more sexual partners and gynecological problems. For STI service use among sexually experienced women, greater odds were noted among older and urban-residing women, women from a disrupted childhood family situation and those with more sexual partners. We were unable to stratify results by survey year due to insufficient sample sizes across sampling strata by year; however, all disparities appeared persistent across time as suggested by insignificant year-by-sociodemographic interaction terms (not shown).

4. Discussion

A rise in young U.S. women’s use of SRH services was noted between 2006 and 2010; among sexually experienced women, SRH and contraceptive service use were stable and STI service use increased. While data are suggestive of reversing negative trends in SRH service use in recent years, levels have not fully recovered to those of 2002 (63%) [9, 10]. Additionally, trends were non-monotonic and after a temporary increase in 2006, SRH service use rates were largely unchanged. Unfortunately, small sub-samples by survey year precluded stratifying regression models by year and thus prevented an adequate description of factors of SRH service use that may be unique to 2006.

Our findings contribute further evidence to the literature showing corresponding trends in SRH services and outcomes among young women in the United States. Between 1995 and 2002, SRH service utilization including contraceptive provision and counseling and STI testing rose [1, 5] along with rising contraceptive and condom use and STI screening and treatment rates and declining teen pregnancy and abortion rates [5]. Following 2002, different trends were noted: increasing teen pregnancy and STI rates and stalled contraceptive use and abortion rates [3, 6, 7] occurred along with declines in SRH service use rates which we previously reported [9]. Our present data suggest stabilized or improving SRH service use in the context of stabilized or improving outcomes following 2006, offering further evidence for the relationship between service use and SRH. However, reasons for changes in pregnancy-related and STI outcomes are likely complex and more direct examinations and formal evaluation of the impact of access to and use of SRH services on young women’s SRH outcomes over time are needed.

Following our previous work, we had hypothesized that worsening economic conditions during the latter part of the decade could contribute to more negative trends in SRH service use [9, 10, 12–14]. A recent Guttmacher Institute survey found that U.S. women reported being forced to delay gynecological or birth control visits or skip birth control use or refill prescriptions as a means of saving money during the years of the economic recession [13]. Additionally, although publicly funded clinics in the U.S. typically serve greater numbers of younger and socially disadvantaged women [1, 12], worsening economic conditions left many previously insured women forced to rely on public services too [12, 15]. This increased demand on SRH health care for publicly funded family planning clinics arose in the context of severe public sector budget cuts and subsequent service delivery challenges, which limited women’s access to services and served as a deterrent to health care seeking [12, 15].

Yet, the Guttmacher survey also found that women have reported intentions or desires to postpone or limit childbearing because of the economy [13], which is consistent with historical trends in family planning outcomes during recession periods [16]. Indeed, the long-term declining trends in U.S. teen pregnancy, birth and abortion and increasing contraceptive use rates continued by 2008 despite temporary interruptions in 2006 [6, 17]. Our findings on the relatively stable SRH service use rates during this time further highlight the competing interests of family planning needs in the context of limited resources that young women in the U.S. and abroad have experienced in recent years.

Disparities in SRH service use across sociodemographics groups continued to exist in 2006–2010. While varying to some extent by type of service, overall, socially disadvantaged and racial/ethnic minority women utilized services less than their counterparts (with the exception of Black women and any SRH service use). Race/ethnicity and residence were more strongly associated with SRH service use in 2006–2010 compared to earlier years, while insurance status, number of partners and gynecological history remained strong predictors similar to years prior [1, 9, 10]. Inequalities in SRH care over the last decade may help to explain the disproportionately negative reproductive health sequelae occurring across demographic and socioeconomic groups throughout these years [2, 6, 8, 17]. Additional investigations of determinants of unmet need for SRH services among minority and socially and economically vulnerable women in current sociopolitical and economic contexts are warranted.

More frequent longitudinal assessments of SRH service use may reveal more dynamic patterns and specific contextual factors which can influence changes in women’s health care seeking over time. Evaluation of the effect of SRH policies and programs and especially the impact of the U.S. health care reform on fluctuating trends and disparities in SRH service use is particularly needed. Broadly, given the exceptionally high rates of poor SRH outcomes in the U.S. compared to other developed countries [2] and the disparities that young U.S. women of demographic minority status and socioeconomic disadvantage experience [3, 5–8], public health approaches to eliminate inequalities in SRH service use and improve SRH for all women appear increasingly warranted.