Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003
MARY ELLEN SIMPSON: Okay. Well thank you very much for the opportunity to be here today and to present the research that we’ve been conducting in Illinois. Sometimes I like to start off with a quick joke or a short story, but I think the joke is on me because last night when I looked at my abstract in the published booklet, it had many mistakes in it and it looks like a mish-mash. I don’t know what happened, but much to my surprise the inclusion of even new co-authors. So what I would I like to say is the joke was on me but a clean version is available and we are listed in your conference attendees, and please feel free to email or give me a phone call and I’ll make sure that you get a good, clean copy. So, with that I’d like to get started. I’m a new assignee to Illinois. I’ve been there about a little over a year and a half, and unintended pregnancies was something that we wanted to get a handle on in this state, so this is a part of a larger study that we have done and conducted on unintended pregnancies.
So primarily today what I want to be telling you about is, we’re using our PRAM’s data to look at “are we missing public health opportunities to provide contraceptive education?” Well I think I don’t have to tell this audience much about what the research has shown about why unintended pregnancy is important. We know that it’s associated with adverse health outcomes, that women are less likely to seek prenatal care in the first trimester or, perhaps, receive no prenatal care at all. Also, women with an unintended pregnancy are less likely to breast feed, more likely to smoke or use alcohol, more likely to have low birth weight, and are also associated with a higher risk for abuse. We know that approximately 50% of pregnancies that are unintended are ended by abortion. About 1/2 of all infants born are unintended, which also has implications for our policy decisions and targeting our resources, and it’s also important to have a handle on this so that we can measure our progress towards a healthy people 20/10 goals of reaching 30% or less.
So, we had three research questions that I’m going to be showing you today. The first is, “What is the profile of a woman most likely to have unintended pregnancy?” The second is, “To what extent is unintended pregnancy result of contraceptive failure?” And “Are we missing opportunities to intervene?” Is there anybody in this room that doesn’t know what the PRAM’s data is? Okay, so I’ll just, kind of, gloss over that but what I’d like to point out on this slide is that in Illinois, we have a response rate of 80.6% which I believe is the highest of all states that participate in PRAM’s, and that’s just due to a fantastic effort on the folks both at CDC and with our PRAM’s folks. So this is a very rich data source and valuable for us to gain insights into women’s experiences in Illinois that represent all of Illinois and not just in our programs, which we tend not to have a lot of information on. And overall each year, we’ve been--‘97 was our first year with PRAM’s. We do not have a full complete year, so ’98 was our first year, and each year, our sample size is just about 2,000. The way pregnancy is assessment of the wantedness which the question is asked, “Thinking back just before you got pregnant, how did you feel about becoming pregnant?” And it was classified as mistimed if they wanted to become at a later point in time, and unwanted if they answered, “I didn’t want to be pregnant then or at any time in the future.” Unintended, then, is a composite of those two combined. Again, the data sources came from PRAM’s, but some of the variables came from the birth certificate data that I’ve listed here.
I’d like to skip right to results. Forty three percent of pregnancies in Illinois from using our PRAM’s data were unintended. This is down a little bit from 1999. In 1999, it was about 44.5%, but overall, of those 43%, 32% were mistimed and 11% were totally unwanted. There was not statistically significant change from 1999, and in 1999 Illinois was the 5th highest for unintended pregnancy reported prevalence among all states that participated in PRAM’s. So, for our first research question, what is the profile of women most likely to have mistimed or unwanted pregnancy? I’ll go through these, kind of, fast but I’d like to draw your attention, anchoring you. For all these slides on the left hand side I just showed you, all burst of the breakout the first column being what was intended and then unintended being broken out by mistimed and then totally unwanted. So there’s no real surprise in here, in that for women that unintended pregnancy is inversely related to age, and so for women less than 20 years of age, about only 25% of their pregnancies were reported as intended or conversely, 75% of all pregnancies to women less than 20 are unintended, and that is broken out by--as you can see--mistimed and unwanted and so it nicely--as you can see the change. What’s interesting is I think that what happens with totally unwanted for women over 35 years of age.
Next, I’d like to show you by maternal race, and again, there’s a big difference for African/American black women. Only 29% of their pregnancies are intended, 46 were mistimed, and 25% of all pregnancies were totally unwanted--were reported unwanted among African/American women. By ethnicity, we looked at Hispanic versus non-Hispanic and there was no significant difference between the two groups. By education, we had really not much difference between those that had less than a high school education and high school education only, but then there was a big jump for those that had beyond a high school education as far as their pregnancy being intended, and fewer that were mistimed and unwanted. By Medicaid status, as you can see, women on Medicaid were more likely to have a pregnancy that was either mistimed or totally unwanted. This goes along, of course, with income as you can see what happens with income. My guess is, is what’s happening here is that’s probably confounded with the women that are 35 years of age and older. And again, for women that are single I think as we saw in our last presentation that single women were--few of their pregnancies are intended, a large portion are mistimed and totally unwanted.
Although some of the research has shown that low birth weight is associated with unintended pregnancies, we didn’t find that in Illinois. There was no significant difference by birth weight. And here we have by WIC status, which again, I’ll tell you why that’s important for us in Illinois, but for women on WIC versus not on WIC there was a large difference of unintendedness of pregnancy. So the strongest predictors of unintended pregnancy in our state was age, primarily less than 20 but also the next age group, 20 to 24 years of age, women that are African/American and single and these were adjusted odds ratios and 95% confidence intervals. So, among women not using contraception, 53% of the women who reported that unintended pregnancy were not using contraception. This was pretty common when I talked to most of the practitioners.
Many of the women said that their pregnancy was unintended but then they didn’t really want to do anything about--if it happened then it just happened. The majority of the reason that was cited on PRAM’s, 31% was because they thought they couldn’t get pregnant. And one I’d like to call your attention to is this last bullet point. About 8% said that they had problems getting birth control when they needed it. So, a summary profile of women not using contraception to avoid pregnancy were single, young, Medicaid eligible women, and they thought they couldn’t get pregnant. So then we wanted to look at what extent was a result of contraceptive failure. And on the PRAM’s data form, unfortunately, there was no information on the method that they used, the consistency nor the woman’s confidence in using that method. Therefore, we really couldn’t determine if the failure was attributed to improper, inconsistent use or efficacy of the method. But what we could tell is that 47% of the women with an unintended pregnancy were using some form of birth control when they became pregnant, and again, the demographic profile of these women was the exact same as those using contraception were single, young, and African/American.
So, are we missing opportunities to intervene? After delivery, 15% of women that answered of the PRAM’s respondents reported that they are not using any method of birth control. Among those that had a previous unintended pregnancy, 13% are not using any birth control post-partum. Primarily, the reason most often given was that they said they were not having sex. However, I’d like to call attention to the second bullet there that 10% said that they can’t afford to pay for birth control, and WIC participants were equally likely not to be using contraception as non-participants. Now, we know that WIC in and of itself does not do counseling in birth control or contraceptive use, but in Illinois, our Family Case Management Program is between 95% and 98% integrated with the WIC population. So we can use that as a good proxy for women that we know that are seen in our services, and as you saw, a disproportionate amount of the women that are affected by unintended pregnancy are in the programs that we serve. One fifth of women responded, “No,” when they were asked during their prenatal visits, “Did a doctor, nurse, or any health care professional, or worker talk to them about birth control to use after their pregnancy?” In 1999, this was around 19%, in 2000 PRAM’s data, it’s now a little over 21%. They were also asked the same question after their baby was born, and again, it was 10% in ’99, it’s now 11% in the 2000 PRAM’s data. We do not have our 2001 data yet, but women are responding that no one is talking to them about birth control after they delivered. Although, in this we did find that WIC participants were more likely to report that they did receive contraceptive information as a non-WIC.
So, in translation of our data to action, we want to target women in the highest risk group profile that we have shown you and provide access to affective contraceptive methods. About 81% of Medicaid eligible women in Illinois participate in our WIC and Medicaid--I’m sorry, Family Case Management Programs, and additional counseling on contraception should be directed to them during pregnancy to prevent another pregnancy that is unwanted or mistimed. Also, to focus counseling on consistency and correct use of method to the high risk group and I’d like to call attention to the last bullet because we’re very excited. Legislation was just passed but narrowly. In Illinois, we are now third party reimbursement for contraceptive if it’s an FDA approved method or device, so it will now be covered by insurance. Limitations, as with any study, there is limitations with this PRAM data. It is self reported and it could be underreported, and I think Dr. Santelli has a very nice paper out that shows that often times, women do change their mind about whether their pregnancy was intended after the fact. So it’s probably--these numbers tend to be an underestimation of unintended pregnancy, and also these behavioral events are reported retrospectively, so the PRAM’s is administered from two to six months after pregnancy--excuse me, after delivery, so we really don’t know if there is a bias in that time frame, and the influence of abortions is unknown. So, in summary, health care providers and family case management programs have an opportunity to reduce the rate of unintended pregnancy through patient education and effective contraception targeted to the high risk groups. Thank you.