ARTICLES Unintended Pregnancy Rates at the State Level By Lawrence CONTEXT: Unintended pregnancy is a key reproductive health indicator, but rates have never been calculated for all B. Finer and 50 states. Kathryn Kost METHODS: State-level estimates of unintended pregnancy rates in 2006 were calculated using data from several sources. The proportion of births resulting from unintended pregnancies was obtained from the Pregnancy Risk Lawrence B. Finer is Assessment Monitoring System and similar state surveys, and the intention status of pregnancies ending in abortion director of domestic research, and Kathryn from a national survey of abortion patients. These proportions were applied to birth and abortion counts for each Kost is senior research state, and fetal losses were estimated. Rates of unintended pregnancy were obtained by dividing relevant fi gures by associate, both at the the number of women aged 15–44 in each state. Six states and the District of Columbia had no appropriate survey Guttmacher Institute, data; their rates were predicted using multivariate linear regression. New York. RESULTS: In 2006, the median state unintended pregnancy rate was 51 per 1,000 women aged 15–44. Most rates fell within a range of 40–65 unintended pregnancies per 1,000 women. The highest rate was in Mississippi (69); the lowest rate was in New Hampshire (36). Rates were generally highest in the South and Southwest, and in states with large urban populations. In 29 states and the District of Columbia, more than half of pregnancies were unintended; in nine, a consistent upward trend in unintended pregnancy rates between 2002 and 2006 was apparent; no state had a consistent decline. CONCLUSIONS: These rates provide benchmarks for measuring the impact on unintended pregnancy of state policies and practices, such as those governing sex education and the funding of contraceptive services. Perspectives on Sexual and Reproductive Health, 2011, 43(2):78–87, doi: 10.1363/4307811 The unintended pregnancy rate is one of the most impor- pregnancy, while black women were nearly three times as tant indicators of a population’s reproductive health. The likely as white women to do so.11 large majority of U.S. women and men want to plan their The dimensions of the problem have long been known pregnancies,1 and improving their ability to do so remains as a result of analyses that combined national-level data on a key goal of the national Healthy People initiative.2 In pregnancy intentions from the National Survey of Family addition, unplanned births have been associated with Growth (NSFG) with national data on births and abortion numerous undesirable outcomes, including inadequate or incidence. However, such estimates have not been calcu- delayed initiation of prenatal care, use of tobacco and alco- lated for each state. Because teenage pregnancy rates,12 hol during pregnancy, premature birth, low birth weight, abortion incidence rates and access to family planning ser- lack of breast-feeding, and negative physical and mental vices13 all vary widely by state, rates of unintended preg- health outcomes among children.3–9 Thus, reductions in nancy may vary as well, among both teenagers and adults. unintended pregnancy rates could have widespread posi- State-level data on unintended pregnancy rates would be tive effects on the health of Americans. highly useful to researchers, service providers, advocates The rate of unintended pregnancy fell nearly 20% and policymakers. For example, absent such rates, it is between the early 1980s and the mid-1990s,10 but it impossible to assess whether decreases in state abortion remained unchanged between 1994 and 2001.11 Although rates are driven by declines in unintended pregnancy rates rates continued to fall among higher income women (those or by other factors, such as harassment of women visiting with incomes at or above 200% of the federal poverty abortion clinics, state restrictions on abortion or public level) in 1994–2001, they rose among the poorest women opinion. Similarly, the lack of state data has hindered efforts (those below 100% of poverty); by 2001, a woman living to gauge the impact of state sex education policies and state- in poverty was four times as likely as a woman living at based efforts to reduce levels of unintended pregnancy, or 200% of poverty or higher to have an unintended preg- to compare levels of teenage pregnancy to overall levels nancy. In addition, racial disparities persisted during this of unintended pregnancy among all women in the state. period: In both 1994 and 2001, Hispanic women were Until recently, data on the intendedness of pregnan- twice as likely as white women to have an unintended cies resulting in births were available only for a limited 78 Perspectives on Sexual and Reproductive Health number of states. However, as of 2007, some 39 juris- data from the closest available year—generally 2005 or dictions had joined the Pregnancy Risk Assessment 2007, though in a few cases it was necessary to use data Monitoring System (PRAMS).14 A surveillance project of from 2002 or 2003 (see appendix, page 84). the Centers for Disease Control and Prevention (CDC) and individual state health departments, PRAMS collects Pregnancy Outcomes state-specifi c, population-based data on maternal attitudes ᭹Births. PRAMS consists of annual surveys of state resi- (including pregnancy intentions) and experiences before, dents who have given birth in the state; the data can be during and shortly after a birth. In addition, seven states weighted to represent all births in the state for the year of have instituted similar surveys. These newly available data the survey. PRAMS surveys were conducted in 31 states in on births, combined with the most complete state-level 2002, in 29 states in 2004, in 28 states in 2006 and in 36 data on abortions, make it possible to estimate unintended states in 2007. In addition, two PRAMS surveys were con- pregnancy rates for all 50 states—the task we undertook ducted in New York—one for New York City and one for in this analysis. the rest of the state—and one was administered among Native American women in South Dakota in 2007. METHODS Other states have (or have recently had) survey pro- Measures grams that are based on or similar to PRAMS and include In this article, a pregnancy is considered unintended if the questions on pregnancy intention. The Pregnancy Risk woman reported that it was mistimed (i.e., she had wanted Assessment Tracking System has been administered to become pregnant, but at a later date) or unwanted (i.e., annually in Idaho since 200131 and was administered she had not wanted to become pregnant then or at any in Connecticut in 2002 and 2003.32 In Wyoming, the time). Intended pregnancies are those that occurred either Maternal Outcomes Measurement System, based on at the time the woman had desired or later. PRAMS, conducted surveys in 2003, 2004 and 2005.33 The inadequacy of this traditional, demographically In California, Maternal and Infant Health Assessment sur- oriented measure of pregnancy intentions and the need veys have collected similar data annually since 2000.34 for more nuanced measures have been widely noted.15–27 In Iowa, the annual Barriers to Prenatal Care survey has For example, a pregnancy classifi ed as unintended may included questions on the intention status of births since have been unexpected and unplanned, but not necessarily 1991.35 The Perinatal Risk Assessment survey has been unwelcome or unwanted. In addition, mistimed pregnan- conducted every two years in South Dakota beginning cies include those that occurred only a little too soon or in 1997, including in 2003, 2005 and 2007.36 Finally, much too soon, and the extent of mistiming appears to be Kentucky began conducting a PRAMS-based survey in an important predictor of maternal behaviors and child 2007.37 health outcomes.28,29 However, although other research Using intention status data from the jurisdictions that and data collection are under way to refi ne measures of carried out at least one round of a PRAMS or similar sur- pregnancy intention, the PRAMS data available for this vey, we were able to directly estimate rates of unintended analysis include only the more limited, traditional mea- pregnancy for 44 states. (We indirectly predicted rates for sure of intention status. the remaining six states and the District of Columbia) For The unintended pregnancy rate for a state is defi ned as each available state, we tabulated the proportion of births the number of such pregnancies per 1,000 women aged that were unintended (and the proportions mistimed 15 –44 residing in the state. Similarly, the intended preg- and unwanted).* These proportions were applied to the nancy rate is the number of intended pregnancies divided total number of births reported for the state in U.S. vital by the same population. Population denominators by age, statistics.38–40 race and ethnic group for each state are based on popu- In some states, the PRAMS survey response rate was lation estimates calculated by the National Center for lower than 70%, the cutoff used by the CDC for inclusion Health Statistics and the U.S. Census Bureau.30 In addition in publicly disseminated fi ndings. Estimates from surveys to these rates, we examine the proportion of all pregnan- with lower-than-optimal response rates can be greatly cies among residents of the state that were unintended. affected by slight variations in the composition of the sam- We also assess the proportions of unintended pregnancies ple. We were cautious in including estimates from surveys that were mistimed and unwanted, as well as the propor- with response rates below 70%. However, for some states, tions ending in birth, abortion and fetal loss (including the only data available on intention status of births came miscarriages).