In a recently released issue of Pediatrics, Dr. Murray Horwitz and colleagues (10.1542/peds.2018-2463) examined trends from 2002-2015 regarding age of sexual debut and age of contraceptive initiation among 26,359 respondents to the National Survey of Family Growth. The authors examined the risk of unwanted pregnancy by timely versus delayed contraceptive initiation, by effectiveness of contraception, and by race/ethnicity and income. “Timely contraceptive initiation” was defined as beginning contraceptive use before or within a month of sexual debut. “Unwanted pregnancy” was selected for the analysis due to its evidence-based relationship with poor prenatal health care, risky maternal health behaviors, and suboptimal birth outcomes. The authors focused specifically on unwanted pregnancies within 3 months of sexual debut.
There’s a lot of good news to read in this interesting article regarding trends in age of sexual debut and timing of contraceptive initiation, and I don’t want to spoil your reading enjoyment by “over-sharing”! I will note that in the studied sample, 493 women (1.8%) endorsed unwanted pregnancy within 3 months of sexual debut, and not surprisingly, delayed contraceptive initiation was significantly associated with this outcome, which held for all races/ethnicities and income groups, and remained significant after adjustment for confounders. The authors graded contraceptives by most effective (long acting reversible contraception and sterilization), effective (pills, patches, rings, injections) and least effective (condoms, pulling out, fertility awareness and emergency contraception), and for those with unwanted pregnancy within 3 months of sexual debut who reported timely contraceptive initiation, there was not an effect of method type, which I did find surprising.
What I found most disturbing were the health inequities revealed in the analysis. Even with a positive trend toward timely contraceptive initiation among all subgroups, rates of timely effective method use declined “substantially but not significantly” from 31% to 17% among non-Hispanic Black women. Additionally, racial/ethnic minority status and household income <400% poverty level remained significant predictors of delayed contraceptive initiation in the multivariate model. The Discussion section does a great job of directly addressing these disparities, and of considering potential mitigation strategies, including increased access via non-traditional settings such as school-based clinics, pharmacies, and urgent care and emergency room settings. It is likely also that there are important influences, such as cultural beliefs, community social norms, and family and partner influences, about which we know too little, that impact this highly personal area of decision-making. The best articles, from my point of view, are those that not just inform, but serve as a call to research and to action, and this is certainly one!
