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

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 care^23,24,26 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.