Skip to main content
American Journal of Public Health logoLink to American Journal of Public Health
. 2012 Feb;102(2):359–367. doi: 10.2105/AJPH.2011.300380

Determinants of and Disparities in Reproductive Health Service Use Among Adolescent and Young Adult Women in the United States, 2002–2008

Kelli Stidham Hall 1,, Caroline Moreau 1, James Trussell 1
PMCID: PMC3483992  PMID: 22390451

Abstract

Objectives. We investigated determinants of and disparities in reproductive health service use among young women in the United States from 2002 to 2008.

Methods. Using data on 4421 US women aged 15 to 24 years from the National Survey of Family Growth (2002, n = 2157; 2006–2008, n = 2264), we employed descriptive and univariate statistics and multivariate regression models to examine service use across women's sociodemographic and reproductive characteristics and to investigate potential disparate changes in service use over time.

Results. More than half the sample (59%) had used services in the past year. In regression models, predictors of service use included age, education, birthplace, insurance, religious participation, mother's education, childhood family situation, age at menarche, sexual intercourse experience, recent number of partners, and previous gynecological diagnosis. Although service use decreased by 8% overall from 2002 to 2006–2008 (P < .001), the magnitude of decline was similar across demographic and socioeconomic groups.

Conclusions. Inequalities in reproductive health service use exist among women in the United States, particularly among the youngest and socially disadvantaged women, which may translate to poor and disparate reproductive outcomes. Public health and policy strategies are needed to eliminate inequities in reproductive health service.


Rates of poor reproductive health and family planning outcomes among young women in the United States, which continue to be higher than in other developed countries,1 disproportionately affect young women of demographic minority status and socioeconomic disadvantage.2–7 Despite overall improvements in contraceptive use and declines in adolescent pregnancy, abortion, and sexually transmitted infections (STIs) occurring prior to 2002,2 progress toward better reproductive health outcomes has since stalled or worsened,2–7 especially among women of certain subpopulations.2,7 In the United States, compared with White women of higher socioeconomic status, young Black and Hispanic women as well as poor and undereducated women have experienced increasingly high rates of unintended pregnancy, abortion, and STIs in recent years.7

Negative reproductive health outcomes appear to be associated with inadequate use of health services,3,8 and differences in the use of reproductive health services among different demographic and socioeconomic groups may contribute to health inequalities. Indeed, our previous analysis of data from the National Survey of Family Growth (NSFG) for 1995 and 2002 revealed that use of reproductive health services varied by women's socioeconomic and demographic backgrounds,9 which mirrored disparities in health outcomes by race/ethnicity, education, and income and poverty levels during that time.7

More recently, we reported on the decline in use of reproductive health services among all young women between 2002 and 2008,8 which coincided with overall worsening reproductive health outcomes.2 This increasing unmet need for health services may be even greater for minority and socially and economically vulnerable women. We sought to investigate determinants of reproductive health service use among young women in the United States from 2002 to 2008 and examine potential disparities in service use across demographic and socioeconomic groups.

METHODS

We used data from the 2002 and 2006–2008 cycles of the NSFG, a large nationally representative survey conducted by the National Center for Health Statistics. The population-based survey collects information on family life, marriage and divorce, pregnancy, infertility, use of contraception, and men's and women's health. Household, in-person interviews with women and men aged 15 to 44 years residing in the United States were conducted by the NSFG in 2002 (wave 6; n = 12 571) and then between 2006 to 2008 (wave 7; n = 13 495).10,11 Black and Hispanic women and men were oversampled. The response rate was 79% in wave 6 and 75% in wave 7. Further information about the design and sampling of the NSFG can be found at the Centers for Disease Control and Prevention Web site.12

We restricted our analysis to adolescent (aged 15–19 years) and young adult (aged 20–24 years) women (n = 5164). Our focus was on use of primary or preventive sexual and reproductive health services, rather than childbearing service use. We examined women who were currently pregnant or who had received prenatal or postpartum care in the previous year (n = 742; 14%) in our preliminary analyses of service use; however, we excluded them from primary analyses because including them produced no differences in estimates of service use. Our final sample included 4421 women: 2157 from 2002 and 2264 from 2006–2008.

We focused on a series of NSFG questions assessing recent preventive or primary reproductive health and family planning service use. Women were asked whether they had visited a medical provider for any reproductive health care 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, contraceptive follow-up evaluation and checkup, contraceptive counseling, and emergency contraceptive provision and counseling), and other gynecological services (Papanicolaou test, pelvic exam, STI testing or treatment, pregnancy testing, and abortion). We considered women to have used reproductive health services if they responded that they had made 1 or more visits to a provider within the last year for any 1 or more of these reasons.

To identify factors associated with service use, we examined several key demographic, socioeconomic, and reproductive history variables. In additional to variables that had been previously shown to be associated with use of reproductive health services,5–7,9,13 we considered additional variables provided by the NSFG that we hypothesized might be associated with the need for or likelihood of service use. Variables of interest included race/ethnicity (Hispanic, non-Hispanic White, non-Hispanic Black, other), education (less than high school diploma, high school diploma, at least some college, still in school), income category (< $25 000, $25 000–$49 999, $50 000–$74 999, ≥ $75 000), poverty level (above or below 200% of poverty level), employment situation (employed, unemployed, still in school, or at home or other), insurance status (uninsured or had any gaps in insurance coverage within last year vs full coverage), birthplace (born in United States or another country), place of residence (urban, suburban, or rural), religious service participation (weekly or more, less than weekly, or never), mother and father's education level (less than high school, high school diploma or general equivalency diploma, or at least some college), childhood family situation (intact = 2 biological or adoptive parents since birth, not intact = anything else), age of mother at first birth, age at menarche, sexual intercourse experience (had vaginal sex vs never had sex), age at first vaginal coitus, number of male sex partners within last 12 months (0, 1, 2, or more), cohabitation or marital experience (yes or no), pregnancy (ever pregnant vs never pregnant), parity (0, 1, or 2 or more births), and previous diagnosis of gynecological problems (yes or no), which may have included ovulation problems, ovarian cysts, uterine fibroids, endometriosis, and pelvic inflammatory disease.

For data analysis, we first used descriptive statistics to describe demographic, social, and reproductive history characteristics and to estimate reproductive health service use, by type of service, focusing on 2 outcomes: (1) having made any reproductive health service visit in the previous year and (2) having received contraceptive services (contraceptive method provision, checkup, or counseling, including emergency contraceptive). We conducted the χ2 test to compare service use across demographic, socioeconomic, and reproductive history variables, both for the total sample and by study period (2002 vs 2006–2008). We also stratified results by sexual experience (ever had sex vs never had sex) and age (adolescents vs young adults). We performed multivariate logistic regression modeling to estimate the influence of each factor on the likelihood of using reproductive health and contraceptive services overall, for 2002, for 2006 through 2008, and for the sexually experienced women. We considered variables for inclusion in regression models if their P value in univariate models was .25 or less. In final reduced multivariate regression models, we retained only those covariates that were significantly associated with the outcome (P < .05) or that significantly changed point estimates of other key variables (e.g., survey year). 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 by creating interaction terms for each sociodemographic variable by survey year and testing these interaction terms in univariate models first, then in multivariate models when needed.

In all analyses, we used weighted data to account for the complex, stratified sampling design of the survey; we computed standard errors and tests of significance using the SVY series of commands in Stata 11.0 (StataCorp LP, College Station, TX).

RESULTS

Demographic, social, and reproductive history characteristics of the total sample (n = 4421) are noted in Table 1. The mean age of the sample was 19 years, with 53% adolescent and 47% young adult women. Regarding race/ethnicity, more than half (56%) of the sample identified as White, 18% as Black, 20% as Hispanic, and 6% as other. Forty-two percent were still in secondary school, whereas 35% reported having had at least some college education. More than half the sample (52%) were below 200% of the poverty level; 25% were uninsured at some point during the previous year. Nearly two thirds of the sample (63%) had experienced vaginal sexual intercourse. Characteristics were similar across survey years, with the exception of employment status. From 2002 to 2006–2008, the proportion of women “in school” increased by 8%, whereas those “at home or other” decreased by 7% (P < .001).

TABLE 1—

Demographic, Social, and Reproductive Characteristics of Adolescent and Young Adult Women in the United States: National Survey of Family Growth, 2002–2008

Total Sample (n = 4421), Mean ±SD or % 2002 (n = 2157; 49%), Mean ±SD or % 2006–2008 (n = 2264; 51%), Mean ±SD or % P (2002 vs 2006–2008)
Demographic and social characteristics
Age, y 19.4 ±2.9 19.5 ±2.8 19.2 ±2.9 .7
 15–19 (adolescents) 53 49 56
 15–17 (younger adolescents) 32 30 34
 18–19 (older adolescents) 21 19 22
 20–24 (young adults) 47 51 44
Race/ethnicity
 Non-Hispanic White 56 57 55 .95
 Non-Hispanic Black 18 18 17
 Hispanic 20 19 21
 Other 6 6 6
Highest level of education attained
 < high school 9 9 9 .94
 High school diploma or GED 14 14 13
 Any college 35 37 34
 Still in high school 42 40 44
Born outside the United States 11 12 10 .31
Residence
 Urban 43 45 41 .22
 Suburban 39 37 40
 Rural 19 18 19
Annual income, $
 < 25 000 35 37 33 .59
 25 000–49 999 22 22 21
 50 000–74 999 13 13 12
 ≥ 75 000 13 13 13
Employment situation
 Employed 55 56 54 < .001
 Unemployed 5 5 5
 In school 23 19 27
 At home or other 17 21 14
Income < 200% of poverty level 52 49 55 .06
Uninsured any time during last 12 mo 25 25 25 .97
Ever cohabitated with partner 28 30 26 .37
Ever married 10 12 8 .24
Attends religious services now ≥ weekly 31 32 30 .87
Mother's education level
 < high school 18 17 18 .32
 High school diploma or GED 31 32 29
 Any college 51 51 52
Father's education level
 < high school 14 16 13 .45
 High school diploma or GED 29 28 31
 > high school 47 48 46
 Not reported 10 8 10
Intact childhood family situation (has had 2 biological or adoptive parents since birth) 56 59 53 .3
Age of mother first birth < 20 y 30 30 29 .37
Reproductive characteristics
Age at menarche, y 12.4 ±1.5 12.4 ±1.5 12.4 ±1.5
 < 11 9 19 9 .42
 11 16 15 17
 12 28 30 27
 13 25 25 26
 14 13 13 14
 > 14 8 8 8
Ever had sexual intercourse
 Yes 63 65 61 .18
 No 37 35 39
Age at first vaginal intercourse, y 16.4 ±2.2 16.3 ±2.2 16.4 ±2.1
 < 15 12 12 11 .52
 15 11 12 10
 16 13 13 13
 17 10 10 11
 18–19 12 12 12
 > 19 5 6 5
 NA 37 35 39
No. of partners last 12 mo
 0 5 7 5 .66
 1 42 45 39
 2 or more 17 17 17
 NA 37 35 39
No. of partners lifetime .5
 0 < 1 < 1 < 1
 1 19 20 18
 2–3 18 19 17
 4–5 11 11 11
 6–10 10 10 9
 > 10 5 5 6
 NA 37 35 39
Ever been pregnant 20 23 18 .09
Pregnancies
 0 43 43 43 .15
 1 11 12 11
 ≥ 2 9 10 7
 NA 37 35 39
Parity
 0 48 48 47 .17
 1 10 11 10
 ≥ 2 5 6 4
 NA 37 35 39
Diagnosed with gynecological problems 13 14 12 .24

Note. GED = general equivalency diploma; NA = not applicable because never had sex. Results are presented as weighted percentages unless otherwise noted. Comparisons across survey years were conducted with χ2 test. Percentages may not add to 100% because of skip patterns in survey items administered or missing responses.

We have reported reproductive health and contraceptive services used from 2002 to 2006–2008 in detail elsewhere.8 Overall, during the previous 12 months, 59% of the total sample used reproductive health services 1 or more times and 48% used contraceptive services 1 or more times. When examined by year, reproductive service use decreased by 8% from 2002 to 2006–2008 (P = .01) and contraceptive service use decreased by 6% (P = .02). Changes in service use from 2002 to 2006–2008 were consistent when stratified by sexual intercourse status and age.

Results of χ2 comparisons of proportions of reproductive health and contraceptive service use among demographic and socioeconomic groups are described in Table 2. For the total sample, factors associated with reproductive health service use included age, race/ethnicity, education, birthplace, poverty level, employment situation, insurance status, religious service participation, mother's education level, childhood family situation, age at menarche, sexual intercourse experience, number of partners in the last 12 months, cohabitation or marital experience, previous pregnancy, parity, and previous diagnosis of a gynecological problem. Contraceptive service use for the total sample was predicted by these same factors minus insurance, mother's education, and childhood family situation. The statistically insignificant interaction terms illustrate the similarity in patterns of health service use across sociodemographic and reproductive history factors from 2002 to 2006–2008.

TABLE 2—

Factors Associated With Use of Reproductive Health and Contraceptive Services Among Young Women in the United States: National Survey of Family Growth, 2002–2008

All Young Women
Sexually Experienced Young Women
Total No. Used Reproductive Health Services (n = 2587; 59%), % P Interaction Term for Survey Year Used Contraceptive Services (n = 2107; 48%), % P Interaction Term for Survey Year Total No. Used Reproductive Health Services (n = 2205, 79%), % P Interaction Term for Survey Year Used Contraceptive Services (n = 1821, 66%), % P Interaction Team for Survey Year
Sociodemographic characteristics
Age group < .001 < .001 < .001 .14
 Adolescents 2326 43 36 989 74 0.24 64 0.67
 Younger adolescents 1416 32 27 402 68 59
 Older adolescents 910 59 52 587 79 68
 Young adults 2095 76 0.34 61 0.54 1793 82 66
Race/ethnicity .01 < .001 .01 < .001
 Hispanic 896 53 42 549 74 58
 White 2476 60 0.59 52 0.38 1565 81 0.93 70 0.62
 Black 785 60 0.73 44 0.25 518 81 0.37 60 0.33
 Other 264 50 0.64 41 0.75 150 73 0.92 60 0.79
Highest level of education < .001 < .001 < .001 < .001
 < high school 389 64 47 332 73 54
 High school 609 71 0.85 63 0.87 540 77 0.65 58 0.79
 Any college 1561 76 0.02 63 0.04 1233 86 0.33 73 0.24
 Still in school 1862 39 0.03 33 0.12 677 71 0.27 62 0.47
Residence .62 .13 .62 .36
 Urban 1910 59 0.83 22 0.89 1200 80 65
 Suburban 1693 58 0.04 53 0.11 1062 79 0.53 65 0.96
 Rural 818 60 97 520 78 0.43 68 0.61
Born outside United States 479 51 .001 0.08 41 .02 0.38 296 71 < .001 0.3 56 < .001 0.68
Born in the United States 3939 59 49 2483 80 67
Annual income, $ .28 .22 .2 .03
 < 25 000 1547 65 52 1122 79 64
 25 000–49 999 972 60 0.66 49 0.71 656 79 0.32 65 0.6
 50 000–74 999 562 62 0.17 50 0.29 366 83 0.46 67 0.81
 ≥ $75 000 562 62 0.12 52 0.14 327 85 0.06 76 0.11
 < 200% of federal poverty level 2285 56 .002 0.24 45 .002 0.27 1423 78 .01 0.3 63 .009 0.27
 ≥ 200% of federal poverty level 2136 61 50 1359 81 68
Employment situation .03 .004
 Employed 2417 69 < .001 56 < .001 1804 82 68
 Unemployed 232 63 0.05 50 0.21 172 76 0.48 60 0.81
 In school 1005 41 0.98 35 0.94 363 76 0.65 69 0.9
 Other 767 49 0.03 36 0.79 443 72 0.36 54 0.24
Uninsured during last 12 mo .002 .12 .01 0.44 .002 0.94
 Yes 1089 64 0.39 50 0.78 859 75 60
 No 3277 57 47 1911 81 68
Attends religious services now < .001 < .001 < .001 < .001
 ≥ weekly 1365 45 0.33 35 0.61 628 75 0.8 59 0.83
 < weekly 3053 64 53 2150 81 0.36 67
Mother's education level .04 .06 < .001 < .001
 < high school 775 53 42 511 71 57
 High school diploma or GED 1350 60 0.13 48 0.19 886 80 0.91 64 0.83
 > high school 2273 59 0.04 49 0.03 1368 82 0.41 70 0.38
Father's education level .71 .85 .04 .02
 < high school 635 55 46 431 75 59
 High school diploma or GED 1282 56 0.41 47 0.24 851 77 0.92 64 0.63
 > high school 2071 55 0.23 49 0.15 1196 83 0.89 71 0.53
Intact childhood family .005 .15 .94 .05
 Has had 2 parents since birth 2475 57 0.71 47 0.84 1501 79 0.23 67 0.11
 Other 1946 61 49 1281 79 64
Age of mother at first birth, y .08 .48 0.71 .3 0.88
 < 20 1306 62 0.85 49 .33 0.74 920 79 63
 ≥ 20 3061 57 47 1831 80 67
Reproductive characteristics
Age at menarche, y .001 .01 .19 .16
 < 11 405 64 50 269 83 64
 11 719 59 0.45 45 0.85 445 79 0.04 61 0.53
 12 1248 58 0.99 48 0.66 807 79 0.83 66 0.56
 13 1116 54 0.84 44 0.83 635 77 0.83 66 0.8
 14 576 55 0.77 47 0.93 369 75 0.52 66 0.97
 > 14 357 71 0.47 60 0.34 252 89 0.69 76 0.62
Ever had sexual intercourse < .001 < .001
 Yes 2782 79 0.58 65 0.87
 No 1639 23 17
Age at first intercourse, y .56 .34 .56 .34
 < 16 517 78 61 517 78 61
 16–17 1506 81 0.52 68 0.55 1506 86 0.52 68 0.55
 18 338 77 0.02 67 0.23 338 77 0.02 67 0.23
 > 18 413 77 0.88 62 0.99 413 77 0.88 62 0.99
No. of partners last 12 mo < .001 < .001 < .001 < .001
 0 1844 27 19 205 54 36
 1 1840 82 0.71 68 0.9 1840 82 0.54 68 0.75
 2 or more 737 80 0.59 66 0.77 737 80 0.25 66 0.93
Ever cohabitated or married < .001 < .001 < .001 0.06 .12 0.02
 Yes 1248 82 0.12 66 0.07 1244 82 66
 No 3173 49 41 1538 77 65
Diagnosed with gynecological problems < .001 < .001 < .001 0.92 < .001 0.65
 Yes 685 80 0.29 67 0.81 501 88 72
 No 3736 54 44 2281 77 64
Ever pregnant 893 83 < .001 0.66 65 < .001 0.65 892 83 .01 0.6 65 .55 0.72
Never pregnant 3528 82 43 1890 78 66
Parity < .001 < .001 .19 .04
 0 3768 54 37 2130 78 66
 1 451 83 0.44 65 0.95 450 82 0.32 65 0.93
 ≥ 2 202 80 0.54 59 0.98 202 79 0.54 59 0.98

Note. GED = general equivalency diploma. Results are presented as weighted percentages of service use for each sociodemographic group. Bivariate tests compare those who have used reproductive health services vs those who have not used services (not shown) for each sociodemographic group. Comparisons across survey years were conducted with χ2 test. Interaction terms are survey year by each variable; P values are from bivariate regression models. The total sample was n = 4421. The sample size of sexually experienced young women was n = 2782.

Factors associated with reproductive health and contraceptive service use among women who had experienced sexual intercourse (n = 2782) were similar to those described for all women with the exception of intact childhood family (P = .94), age at menarche (P = .19), and parity (P = .19) (Table 2).

Multivariate logistic regression models illustrating the influence of key demographic, socioeconomic, and reproductive history variables on service use are provided in Table 3. In the final model, predictors of reproductive health service use included survey year, age, education, birthplace, insurance status, religious participation, mother's education, childhood family situation, age at menarche, sexual intercourse experience, number of sexual partners in last 12 months, and previous gynecological diagnosis (Table 3). Predictors were similar among young women who were sexually experienced, with the exceptions of age, mother's education, childhood family situation, and age at menarche, which were not significant in models.

TABLE 3—

Logistic Regression Models Predicting Reproductive Health Service and Contraceptive Use Among Young Women in the United States: National Survey of Family Growth, 2002–2008

Reproductive Health Service Use
Contraceptive Use
Total Sample Full Model (n = 4421), OR (95% CI) Total Sample Reduced Model (n = 4421), OR (95% CI) 2002 Reduced Model (n = 2157), OR (95% CI) 2006–2008 Reduced Model (n = 2264), OR (95% CI) Had Sex Reduced Model (n = 2782), OR (95% CI) Total Sample Full Model (n = 4421), OR (95% CI) Total Sample Reduced Model (n = 4421), OR (95% CI) 2002 Reduced Model (n = 2157), OR (95% CI) 2006–2008 Reduced Model (n = 2264), OR (95% CI) Had Sex Reduced Model (n = 2782), OR (95% CI)
Year (2002 vs 2006–2008) 0.6 (0.5, 0.8) 0.6 (0.5, 0.8) x x 0.7 (0.6, 1.0) 0.7 (0.6, 0.9) 0.8 (0.6, 0.9) x x 0.8 (0.6, 1.0)
Age group, y x x x x
 15–17 (Ref) 1.0 1.0 1.0 1.0 1.0 1.0
 18–19 1.4 (1.0, 2.0) 1.5 (1.1, 2.1) 2.0 (1.3, 3.1) 1.3 (0.8, 2.0) 1.2 (0.9, 1.6) 2.1 (1.4, 3.4)
 20–24 2.0 (1.4, 3.0) 2.1 (1.5, 3.0) 3.1 (2.0, 4.8) 1.7 (1.1, 2.7) 1.3 (0.9, 1.9) 2.6 (1.5, 4.5)
Race/ethnicity x x x x x x x
 Hispanic (Ref) 1.0 1.0 1.0
 White 1.0 (0.8, 1.4) 1.3 (0.8, 2.0) 1.2 (0.9, 1.6)
 Black 1.3 (0.9, 1.8) 1.8 (1.1, 2.9) 1.0 (0.7, 1.2)
 Other 1.0 (0.6, 1.7) 1.1 (0.5, 2.5) 1.0 (0.6, 1.8)
Education x
 < high school (Ref) 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0
 High school or GED 1.5 (0.9, 2.3) 1.5 (1.0, 2.4) 1.7 (1.0, 2.8) 1.3 (0.8, 2.2) 1.3 (0.8, 2.0) 1.5 (1.0, 2.3) 1.5 (0.9, 2.4) 1.4 (0.7, 2.6) 1.3 (0.8, 1.9)
 Any college 2.0 (1.2, 3.1) 2.1 (1.3, 3.3) 3.4 (2.0, 5.6) 2.0 (1.1, 3.4) 2.1 (1.4, 3.0) 2.6 (1.9, 3.5) 3.1 (2.2, 4.5) 1.7 (1.0, 2.9) 2.3 (1.6, 2.8)
 Still in school 1.5 (1.0, 2.3) 1.6 (1.0, 2.4) 1.5 (0.9, 2.4) 1.1 (0.7, 2.0) 1.6 (1.1, 2.4) 1.7 (1.2, 2.3) 1.9 (1.2, 2.9) 2.1 (1.1, 3.8) 1.5 (1.0, 2.2)
Residence x x x x x x x x x x
 Urban
 Suburban
 Rural
Born outside United States 0.7 (0.5, 0.9) 0.7 (0.5, 0.9) 0.5 (0.4, 0.8) x 0.6 (0.4, 0.9) 0.8 (0.6, 1.1) 0.7 (0.6, 1.0) 0.6 (0.5, 0.9) x 0.6 (0.5, 0.9)
Annual income, $ x x x x x x x x x x
 < 25 000
 25 000–49 999
 50 000–74 999
 ≥ 75 000
< 200% federal poverty level 0.9 (0.7, 1.1) x x x x 1.0 (0.8, 1.2) x x x x
Employment x x x x x x x x
 Employed (Ref) 1.0 1.0
 Unemployed 0.8 (0.5, 1.3) 0.9 (0.6, 1.5)
 In school 1.0 (0.7, 1.3) 1.0 (0.8, 1.3)
 Other 0.8 (0.6, 1.1) 0.7 (0.6, 1.0)
Uninsured last year 0.7 (0.6, 1.0) 0.7 (0.6, 1.0) x 0.7 (0.4, 1.1) 0.7 (0.5, 0.9) 0.7 (0.6, 0.9) 0.7 (0.6, 0.9) 0.8 (0.6, 1.0) 0.7 (0.4, 0.9) 0.7 (0.6, 0.9)
Attends religious services now
 ≥ Weekly (Ref) 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0
 < weekly 1.6 (1.3, 2.1) 1.5 (1.3, 2.1) 1.4 (1.1, 1.8) 2.0 (1.3, 2.9) 1.6 (1.2, 2.2) 1.6 (1.2, 2.0) 1.6 (1.3, 2.0) 1.5 (1.1, 2.0) 1.7 (1.2, 2.3) 1.6 (1.2, 2.1)
 Never 1.3 (1.0, 1.8) 1.3 (1.0, 1.8) 1.1 (0.8, 1.4) 1.7 (1.1, 2.7) 1.2 (0.8, 1.6) 1.4 (1.1, 1.8) 1.4 (1.1, 1.9) 1.2 (0.9, 1.7) 1.9 (1.3, 2.8) 1.4 (1.0, 1.8)
Mother's education x x x x
 < high school (Ref) 1.0 1.0 1.0 1.0 1.0 1.0
 High school diploma or GED 1.3 (1.0, 1.8) 1.4 (1.0, 1.8) 1.3 (0.9, 2.0) 1.5 (1.0, 2.3) 1.4 (1.0, 2.0) 1.1 (0.8, 1.5)
 > high school 1.3 (1.0, 1.8) 1.4 (1.1, 1.8) 1.5 (1.0, 2.3) 1.4 (0.9, 2.0) 1.4 (1.0, 2.0) 1.2 (0.9, 1.6)
Intact child family (has had 2 parents since birth) 0.8 (0.6, 0.9) 0.7 (0.6, 0.9) 0.8 (0.6, 1.0) 0.7 (0.6, 1.0) 0.8 (0.6, 1.0) 0.9 (0.7, 1.1) x x x x
Age at menarche, y x x x x
 < 11 (Ref) 1.0 1.0 1.0 1.0 1.0 1.0
 11 1.0 (0.6, 1.5) 1.0 (0.6, 1.5) 0.7 (0.3, 1.3) 0.7 (0.4, 1.3) 0.8 (0.5, 1.2) 0.7 (0.4, 1.3)
 12 0.6 (0.4, 0.8) 0.6 (0.4, 0.8) 0.5 (0.3, 0.9) 0.6 (0.3, 1.0) 0.7 (0.5, 0.9) 0.7 (0.4, 1.1)
 13 0.6 (0.4, 0.9) 0.6 (0.4, 0.9) 0.5 (0.3, 0.9) 0.6 (0.3, 0.9) 0.7 (0.5, 1.0) 0.6 (0.3, 1.0)
 14 0.5 (0.4, 0.8) 0.6 (0.4, 0.8) 0.4 (0.2, 0.8) 0.5 (0.3, 0.9) 0.6 (0.4, 0.9) 0.6 (0.3, 1.0)
 > 14 0.9 (0.6, 1.5) 0.9 (0.6, 1.5) 0.8 (0.4, 1.6) 1.0 (0.6, 1.7) 1.0 (0.6, 1.6) 1.0 (0.5, 1.8)
Ever had sexual intercourse 2.6 (1.7, 4.0) 2.6 (1.7, 4.0) 2.4 (1.5, 3.8) 3.0 (1.4, 6.5) x 1.8 (1.1, 2.8) 1.8 (1.1, 2.7) 2.0 (1.2, 3.4) 8.4 (5.3, 13.3) x
≥ 2 partners last y 5.0 (3.3, 7.4) 5.0 (3.3, 7.4) 5.8 (3.5, 9.6) 4.1 (2.0, 8.4) 5.0 (3.3, 7.5) 6.3 (4.2, 9.4) 6.4 (4.3, 9.5) 5.4 (3.4, 8.8) x 6.2 (4.1, 9.3)
Gynecological diagnosis 3.9 (2.7, 5.6) 3.8 (2.6, 5.5) 4.3 (2.8, 6.5) 3.8 (2.2, 6.4) 2.9 (1.9, 4.2) 3.0 (2.2, 4.2) 3.1 (2.3, 4.3) 2.8 (1.9, 4.2) 3.1 (2.0, 5.0) 2.1 (1.5, 2.8)

Note. CI = confidence interval; GED = general equivalency diploma; OR = odds ratio. An x indicates a variable was not significant and was not included in final model.

Differences were noted in models for 2002 and 2006–2008. Education, birthplace, and age at menarche were predictors of reproductive health service use in 2002 but not in 2006–2008. Age, race/ethnicity, and insurance were predictors in 2006–2008 but not in 2002. Age-by-year was the only significant interaction term found in regression models, such that older women were increasingly more likely than younger women to use services over time. We did not include the interaction term in final models, however, since it did not change point estimates.

Determinants of contraceptive service use were similar to those described for reproductive health service use (Table 3).

DISCUSSION

Our findings suggest that disparities exist in reproductive health service use among women in the United States. Younger women and undereducated, underinsured, and immigrant women had lower rates of service use between 2002 and 2006–2008 than older women and women of higher socioeconomic status. These differentials in service use mirror the disproportionately negative reproductive health sequelae occurring across demographic and socioeconomic groups during the last decade.2–7 Together, this picture is consistent with historical patterns of inequalities in family planning and reproductive health care and corresponding disparate outcomes.9,13–16

Regarding changes over time, we found a significant decrease in service use by young women between 2002 and 2006–2008, which we have reported in detail elsewhere8 and which is in sharp contrast to the promising positive trends noted in the previous years.2,9 In this analysis, with the exception of age, we found no interactions by survey year—the magnitude of decline in service use was experienced similarly among women from different demographic and socioeconomic backgrounds. These results are a departure from our own previous data examining inequalities in reproductive health visits by US women between 1995 and 2002,9 in which widening demographic and socioeconomic gaps were noted. Between 1995 and 2002, younger women saw greater increases in contraceptive service use than older women; immigrant, undereducated, and uninsured women experienced smaller increases in contraceptive service use and decreases in other preventive reproductive health service use than women of higher socioeconomic status.9

Our findings may be a reflection of changing social, economic, and political contexts in which reproductive services were needed and provided over the last decade. For example, declining numbers of public sector clinics since 2000, which typically serve greater numbers of younger and socially disadvantaged women,9,17 left many women without access to care. These women have traditionally used family planning clinic services at higher rates than their peers, so declining use among these women may have helped decrease service use overall,8 subsequently narrowing the socioeconomic gap and changing the age distribution previously noted in our introduction.

In more recent years not fully covered by our data, unemployment and lack of insurance have increasingly affected all women, including those who typically receive care outside of the public sector.17–19 These women have been forced to go without care or to rely on public services too,16–19 which may be minimizing previously existing social differentials in reproductive health service use.18 Differences in our regression models for each survey year illustrate the growing impact of insurance, as it was a predictor of reproductive health service use in 2006–2008 but not in 2002. These trends may be more apparent in forthcoming NSFG data from 2008 to 2010, which we intend to analyze and which may also reflect the worsening budget situations for public sector clinics.20 The impact of health care reform on preventive care for young women,21 on the other hand, will also be relevant and will need future research consideration.

The growing disparity in service use by younger women may be attributed not only to increasingly limited clinical resources for care but also to updated gynecological guidelines that recommend less frequent Papanicolaou test screenings and more conservative management strategies.22

More broadly, however, our findings may reflect the influence of the socially conservative US government administration on reproductive health and family planning during our study years.23–26 Abstinence-focused strategies to reduce adolescent pregnancy have been unsuccessful in improving reproductive health outcomes, by delaying first sexual intercourse but not deterring risky sexual activity.25 This is further evidenced and compounded by our findings that sexual experience, not age at first sexual experience, appears to matter with regard to sexual and reproductive health service use. Moreover, legislation that has increased mandatory parental involvement with adolescents’ sexual and reproductive health care23,24,26 has also restricted reproductive health programs and services, limiting access to care and denigrating healthy sexual behavior. These efforts have disproportionately affected adolescent women, who often experience the worst outcomes and have the greatest unmet needs for comprehensive, quality reproductive health services.25,26 Additional research is needed to understand the potentially differential impact of conservative, restrictive programs and policies on reproductive health service use among certain sociodemographic groups of women in the United States.

In sum, our findings show that inequalities in reproductive health care for women in the United States exist, and they disproportionately affect young, minority, and socioeconomically disadvantaged women. Disparities in service use may reflect changing social and political factors that undermine confidential reproductive health care for all women but particularly for women of certain sociodemographic groups. Given that disparate, unmet needs for reproductive health care facilitate inequalities in reproductive and family planning sequelae, public health and policy strategies are needed now to eliminate inequities in service use and improve outcomes for all women.

Acknowledgments

This work was supported in part by a training fellowship (to K. S. Hall) from the Center for Health and Wellbeing, Office of Population Research, Princeton University.

Human Participant Protection

This study was approved by the Princeton University institutional review board.

References

  • 1.Darroch JE, Frost JJ, Singh Set al. Teenage sexual and reproductive behavior in developed countries. Guttmacher Occasional Rep. 2001;3:1–120 [Google Scholar]
  • 2.Gavin L, MacKay AP, Brown Ket al. Sexual and reproductive health of persons aged 10–24 years—United States, 2002–2007. MMWR Surveill Sum. 2009;58(6)1–58 [PubMed] [Google Scholar]
  • 3.Suellentrop K. Adolescent girls’ use of health services. Science says, September 2008. Available at: http://www.teenpregnancy.org/works/pdf/Science_Says_28_girls_health.pdf. Accessed March 2, 2011
  • 4.Mosher WD, Martinez GM, Chandra A, Abma JC, Wilson SJ. Use of contraception and use of family planning services in the United States: 1982–2002. Adv Data. 2004;350:1–36 [PubMed] [Google Scholar]
  • 5.Abma JC, Martinez MG, Copen CE. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, National Survey of Family Growth 2006–2008. Vital Health Stat 23. June 2010;(30):1–47 [PubMed] [Google Scholar]
  • 6.Kost K, Henshaw S, Carlin LUS. teenage pregnancies, births and abortions: national and state trends and trends by race and ethnicity. Guttmacher Institute, January 2010. Available at: http://www.guttmacher.org/pubs/USTPtrends.pdf. http://www.guttmacher.org/pubs/USTPtrends.pdf. Accessed March 2, 2011
  • 7.Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38(2):90–96 [DOI] [PubMed] [Google Scholar]
  • 8.Hall K, Moreau C, Trussell J. Discouraging trends in reproductive health service use among adolescent and young adult women in the United States: an analysis of data from the National Survey of Family Growth, 2002 to 2008. Hum Reprod. 2011;26(9):2541–2548 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Potter J, Trussell J, Moreau C. Trends and determinants of reproductive health service use among young women in the USA. Hum Reprod. 2009;24(12):3010–3018 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Lepkowski JM, Mosher WD, Davis KE, Groves RM, Van Hoewyk J. The 2006–2010 National Survey of Family Growth: sample design and analysis of a continuous survey. National Center for Health Statistics. Vital Health Stat 2. June 2010;(150):1–36 [PubMed] [Google Scholar]
  • 11.Lepkowski JM, Mosher WD, Davis KE, Groves RM, van Hoewyk J, Willem J. National Survey of Family Growth, Cycle 6: sample design, weighting, imputation, and variance estimation. Vital Health Stat 2. July 2006;(142):1–82 [PubMed] [Google Scholar]
  • 12.Centers for Disease Control and Prevention National Survey of Family Growth. Available at: http://cdc.gov/nchs/nsfg.htm. Accessed November 19, 2011
  • 13.Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of US women: data from the 2002 National Survey of Family Growth. Vital Health Stat 23. December 2005;(25):1–160 [PubMed] [Google Scholar]
  • 14.Frost JJ. Trends in women's use of sexual and reproductive health care services, 1995–2002. Am J Public Health. 2008;98(10):1814–1817 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Guttmacher Institute Contraceptive needs and services, 2006. Available at: http://www.guttmacher.org/pubs/win/allstates2006.pdf. Accessed March 2, 2011
  • 16.Frost JJ, Henshaw SK, Sonfield A. Contraceptive Needs and Services: National and State Data, 2008 Update. New York, NY: Guttmacher Institute; 2010 [Google Scholar]
  • 17.Guttmacher Institute A real time look at the impact of the recession on publically funded family planning centers. Guttmacher Policy Rep. December 2009:2–10 [Google Scholar]
  • 18.Guttmacher Institute A real-time look at the impact of the recession on women's family planning and pregnancy decisions, September 2009. Available at: http://www.guttmacher.org/pubs/RecessionFP.pdf. Accessed March 1, 2011
  • 19.American College of Obstetricians and Gynecologists Bad economy blamed for women delaying pregnancy and annual check-up. News release, May 5, 2009. Available at: http://www.acog.org/from_home/publications/press_releases/nr05-05-09-1.cfm. Accessed March 1, 2011
  • 20.Guttmacher Institute Contraception works—and publicly funded family planning programs are essential to reduce unintended pregnancy and abortion. Available at: http://www.guttmacher.org/media/inthenews/2011/03/09/index.html. Accessed March 10, 2011
  • 21.Sonfield A, Gold RB. Holding on to health reform and what we have gained for reproductive health. Contraception. 2011;83(4):285–288 [DOI] [PubMed] [Google Scholar]
  • 22.American Congress of Obstetrics and Gynecologists ACOG announces new Pap smear and cancer screening guidelines. Available at: http://www.acog.org/acog_districts/dist_notice.cfm?recno=13&bulletin=3161. Accessed March 2, 2011
  • 23.Dailard C. Legislating against arousal: the growing divide between federal policy and teenage sexual behavior. Guttmacher Policy Rev. 2006;9(3):12–16 [Google Scholar]
  • 24.Dailard C, Richardson CT. Teenagers’ access to confidential reproductive health services. Guttmacher Rep Public Policy. 2005;8(4):6–11 [Google Scholar]
  • 25.Boonstra HD. Advocates call for a new approach after the era of “abstinence-only” sex education. Guttmacher Policy Rev. 2009;12(1):6–11 [Google Scholar]
  • 26.Jones RK, Boonstra H. Confidential reproductive health services for minors: the potential impact of mandated parental involvement for contraception. Perspect Sex Reprod Health. 2004;36(5):182–191 [DOI] [PubMed] [Google Scholar]

Articles from American Journal of Public Health are provided here courtesy of American Public Health Association

RESOURCES