Contraceptive preferences and unmet need for contraception in midlife women: where are the data?
Harlow et al. Women's Midlife Health
Contraceptive preferences and unmet need for contraception in midlife women: where are the data?
Siobán D. Harlow 0 1
Jennifer R. Dusendang 1
Michelle M. Hood 1
Nancy Fugate Woods 2
0 Department of Epidemiology, University of Michigan 1415 Washington Heights , Suite 6610 SPH I, Ann Arbor, Michigan , USA
1 Department of Epidemiology, University of Michigan , Ann Arbor, Michigan , USA
2 Biobehavioral Nursing and Health Informatics, University of Washington , Seattle, Washington , USA
This commentary discusses the limited availability of information on contraceptive preferences and unmet need for contraception among midlife women in both high and low income countries. Given that risk of pregnancy continues until women reach menopause and given the increased risk of pregnancy complications, elective abortion, and maternal mortality in women aged 45 to 54 years old, increased focus on gathering basic data on midlife women's preferences and unmet need is warranted.
Contraception; Menopause; Midlife; Women's health
Midlife marks a period of declining fertility as women
approach and complete the transition to menopause [
With reproductive aging, the number of antral follicles
decline and the ovary becomes less responsive to follicle
stimulating hormone (FSH), leading to increasing
irregularity in menstrual periodicity, more frequent luteal
phase insufficiency and anovulation. Nonetheless, the
possibility of pregnancy continues until women reach
menopause, as relatively normal ovulatory cycles have
been documented to occur up until the time of the final
menstrual period (FMP) [
]. It is recommended that
women aged 50 to 55 years of age continue
contraception until after at least 1 year of amenorrhea and that
women under 50 years continue until after at least 2
years of amenorrhea [
]. Although much attention has
been paid in recent years to enhancing the fertility
potential of women in their 40s who are seeking to become
], few studies have addressed the unmet need
for contraception or evaluated the contraceptive
preferences of midlife women. Alkema and colleagues [
recently published a comprehensive global review of the
prevalence of contraceptive use and unmet need by
country using the United Nations Population Division
database, however, that report did not disaggregate the
data by age.
Data are particularly limited for midlife women in
highincome countries. For example, the median age at
menopause in the United States (US) is 51.4 years [
approximately 50% of women in their early to mid-50s,
who have not had a hysterectomy, remain at potential risk
of pregnancy. Yet, few studies in the US are able to
provide information on contraceptive practices of women
older than 45 years of age. The National Survey of Family
Growth has historically collected data on women aged 15
to 44, although in 2015 the eligible age range was
expanded to 15–49 years [
]. The Behavioral Risk Factor
Surveillance System (BRFSS) does not administer the
family planning module to women aged 45 years and older,
with the exception of the state of Massachusetts [
cohort studies, such as the Nurses’ Health Study and the
Study of Women’s Health Across the Nation (SWAN),
obtained information only on hormonal forms of
contraception as their interest was in understanding
health risks of hormone exposures and hormone therapy
practices for symptoms of menopause. The National
Health and Nutrition Examination Survey (NHANES)
provides data for women up through age 54 years,
however, this survey inquired only about hormonal forms of
contraceptive use, specifically oral contraceptive pills and
In the 2006–2008 National Survey of Family Growth,
78% of women aged 40–44 reported using
contraception, with sterilization the most frequently reported
among those using contraception (50.2% female and
19.6% male) [
]. Oral contraceptive use was reported
by 11.1% with only 1.1% reporting use of injectable
contraception. Condom use was reported by 8.8%, the
intrauterine device by 4.2%, and other methods
including natural family planning by 5.1%. It was estimated
that 7.6% of women in this age group are at risk of
pregnancy and not using contraception [
The Massachusetts BRFSS ascertained contraceptive
use for women aged 18 to 50 years old [
women aged 45–50 were less likely to be sexually active
and more likely to have had a hysterectomy than
younger women, 78% remained potentially at risk of
unintended pregnancy. Of these potentially at-risk women,
67% reported using some form of contraception: 44%
had had a tubal ligation or their partner had had a
vasectomy, 3.3% used intrauterine devices or implants, 5.9%
used hormonal contraceptives, 11.6% used barrier
methods and 2.1% used other methods. At-risk women
in this age group were more likely not to use
contraception than younger women (16.8% as compared to 9.3%
of 18–24 year olds, 11.3–11.7% of 25 to 39 year olds,
and 14.7% of 40–44 year olds). These data are specific to
the state of Massachusetts and may not reflect the
national experience: The reported frequency of
hysterectomy (9.2%) is lower than the national average. Access
to contraceptive services also differs state by state.
The NHANES data are limited to information on use of
birth control pills and the injectable depo-provera [
used data from the 2011–2012 survey [
] to assess
potential unmet need for contraception and use of these two
types of contraceptives among women aged 40 to 54 years
of age. Table 1 provides information on the percent of
women who are at risk of pregnancy (women who are
sexually active, have not had a hysterectomy and are not
aNational Health and Nutrition Examination Survey, 2011–2012 https://wwwn.
bAt-risk women include women who are sexually active, have not had a
hysterectomy and are not postmenopausal
postmenopausal), with women aged 35–39 included for
comparison. The percent of women at risk of pregnancy
declines from 70% of women aged 40–44 to 56% of women
aged 45–49 to 24% of women aged 50–54 years old.
Among at risk, sexually active women, oral contraceptive
pill (OCP) use was reported more frequently than
depoprovera (See Table 2). OCP use was reported by 13% of the
at-risk 40 to 44 year olds and 17.6% of the at-risk 45–49 year
olds compared to less than 1 % for depo-provera. Less than
2% of the at-risk 50–54 year olds reported use of either
method. Depo-provera use was more frequent in Black and
Hispanic women (prevalence <3%) than in White women.
Notably, most at-risk women aged 40–54 years did not use
either method. Although somewhat informative about
national contraceptive practices, these data are limited by
the lack of information on permanent sterilization, barrier
methods and other forms of contraception. Also, the
weighted data are based on just 743 women, just 427 of
whom were sexually active and at risk of pregnancy,
making it difficult to conduct further subgroup analysis.
These limited US data, along with data on elective
], suggest that an appreciable percentage of
midlife women potentially have an unmet need for
contraception. This unmet need is particularly
worrisome given the increased risk of pregnancy
complications and maternal mortality in women age 40 and older
]. In 2013, US birth rates were 10.4 births per 1000
women aged 40–44, 0.8 births per 1000 women aged
45–49, and 0.7 births per 10,000 women aged 50–54
]. However, these calculations do not take into
account the fact that many women aged 40 and older are
not at risk of pregnancy because of hysterectomy or
menopause. Based on the NHANES data in Table 1, at
most 68% of women aged 45–49 and 35% of women
aged 50–54 are at risk of pregnancy, thus birth rates for
these two age groups are likely closer to 1.2/1000 and
2/10,000 women at-risk, respectively.
Although only 15% of births are to mothers age 35
and older, over 27% of maternal death occur to mothers
in this age group [
]. Significant race/ethnic disparities
aNational Health and Nutrition Examination Survey, 2011–2012 https://wwwn.
exist, with non-Hispanic- African American women
having more than a threefold higher risk of a pregnancy
related death than non-Hispanic whites (38.9 versus 12.0
deaths/100,000 live births respectively). This disparity
increases with age reaching approximately 148 deaths per
100,000 live births for African American women aged 40
and older compared to approximately 35 per 100,000
for whites. Thus, information on desire for pregnancy,
contraceptive preferences and barriers to access is of
particular importance to address these health disparities.
Information on contraceptive practices in other
highincome countries is also limited. Most studies from
Europe are 15–20 years old, have data only through age
44, and were based on small samples [
]. In 2003, a survey
of over 12,000 women aged 15 to 49 years was conducted
in France, Germany, Italy, Spain, and the United Kingdom
but the report provides only limited information about
age specific practices [
]. Sterilization was most common
in women over age 40, while use of long-term, reversible
contraception was most common in women aged 35–44.
About one-third of women aged 45–49 did not use any
form of contraception.
A survey on contraception and sexual health was
undertaken by the United Kingdom’s Office for National Statistics
in 2008/09 and included women aged 40–49 years old [
Most women used some contraception with 75% of 40–
44 year olds and 72% of 45–49 year olds currently using
contraception. Sterilization was the most commonly used
form of contraception with 46 and 49%, respectively
reporting that either they or their partner had been sterilized.
Male partners were more likely to be sterilized than the
women themselves. The next most commonly reported
contraceptives were condoms (21 and 11%) and oral
contraceptives (10 and 13%), respectively. Natural family
planning/rhythm/withdrawal was reported by 10 and 9%,
and the intrauterine device by 9 and 11%. Other types of
hormonal contraceptives and other barrier methods were
each used by 5% in both age groups.
A Canadian internet based survey of women aged 15
to 50 years who were sexually active and not pregnant
] reported that among women aged 40 and older,
60% never used contraception while 33% always used
contraception, with the 1.7% of women who had had a
hysterectomy included in the always used category.
Information on menopausal status was not available.
Nonuse of contraception was associated with lower income,
lower education, rural residence and being married.
Women were able to indicate use of more than one type
of contraception. The most commonly used
contraceptives reported by women of this age group were
condoms (42.5%) and sterilization of either partner (36.0%).
Oral contraceptive use was reported by 17.1%, while
other types of hormonal contraceptives were used by
4.8%. Natural family planning/withdrawal was reported
by 17.1% and barrier methods by 7.5%.
Considerably more data are available from low-income
countries (LICs) given the historic focus of the
Demographic and Health Surveys (DHS) on
contraceptive behavior, although these surveys generally only
include information on women up through age 49. The
problem of unmet need in LICs has received
considerable attention [
], but few papers specifically address the
unmet need for midlife women [
]. Table 3 compiles
data from the country-specific DHS survey reports from
African countries surveyed between 2006 and 2015. The
table provides information on the percent of women
who report not using any contraception as well as
fertility rates and, where reported, the estimated
maternal mortality per 1000 women [
]. We focused on
unmet need, given that contraceptive use remains low in
most countries. In most countries, the percent of women
not using contraceptives increases from age 40–44 to
age 45–49 years, although fertility at these ages remains
substantial. Of note, in sub-Saharan Africa, 10 countries
had higher rates of estimated maternal mortality among
women age 45 to 49 than in women aged 40–44, despite
older women having lower fertility. Information on
global abortion rates is not disaggregated by age [
Commentary and recommendations
The median age of menopause is approximately 51 years
of age with about 95% of women reaching their final
menses by age 54 years [
]. Limited national
surveillance data are available in high-income countries about
contraceptive practices of midlife women, while unmet
need for contraception increases among midlife women
in low and middle-income countries, despite women’s
potential fertility until the time of menopause.
Examination of available data from large national studies
in the US reveals that even in the presence of data for
women over 40 years of age, these data are often
incomplete with respect to the types of contraception women
use or whether women have experienced hysterectomy or
ovariectomy. The NHANES collects data on
contraception from women up to 54 years of age, but does not
inquire about use of sterilization, IUD/IUS, barrier or
natural family planning methods. Until the current round
of data collection, the NSFG data only extended to 44 year
olds, providing no information about women aged 45–54
who are still potentially at risk of pregnancy. BRFSS data
on family planning are limited to women younger than 45,
although one state includes data on women up to age
50 years, providing no data on those 51–54 years of age.
Based on examination of these studies, we recommend
that all studies of contraception using national or state
Burkina Faso 2010
Not married/Active 40.0
Not married/Active 41.6
Congo Republic 2011–2012
Not married/Active 29.6
Congo Democratic Republic 2013–2014
Not married/Active 57.9
Cote d’Ivoire 2011–2012
Equatorial Guinea 2011
Not married/Active 80.7
population samples increase the upper age boundary to
include women up to and including 54 years of age. In
addition, we recommend that these studies include data
on sterilization (both male and female), IUD/IUS use,
contraceptive implants, barrier, and natural family
planning methods as well as whether women are
menopausal and sexually active. Recognition that some
women employ multiple methods supports reporting
commonly used combinations. Given that many midlife
women have had experience with using contraceptive
methods throughout their reproductive lifespan, we can
learn from their contraceptive practice patterns about
the types of contraceptives and sequences and
combinations they use and prefer in late reproductive life and
during the menopausal transition.
Global patterns of contraceptive use by midlife women
differ across the US, Europe and Canada and across low
and middle-income countries. Data from Europe
indicate that women over 40 years most commonly rely on
sterilization or LARC, but 1/3 use no contraceptive
methods. The UK data indicate that over 70% of women
40–49 years of age use contraception with nearly 50%
relying on sterilization. Barrier methods (especially
condoms) account for about 20% of women’s use and
IUD, oral contraceptive and natural family planning each
about 10%. In contrast to the UK, in Canada only 33%
of women always used contraception with 40% relying
on condoms and 36% on sterilization. For women in low
income countries unmet need for contraception remains
high overall, but notably increases after age 40 years
when rates of maternal mortality also increase. Given
the increased risk of maternal mortality for women after
age 40 years, further research is warranted about unmet
need for contraception in this age group in low and
middle income countries. In addition, evidence for US
women underscores the increased risk of maternal
mortality for midlife African American women compared to
White women, indicating potential health disparities in
contraceptive access. Data on the intendedness of births
and barriers to contraceptive utilization during this
lifestage is lacking.
Midlife women begin to experience an increasing
prevalence of chronic illnesses such as hypertension and
diabetes and thus risks associated with specific
contraceptive choices also change. For midlife women who desire to
prevent pregnancy, or to become pregnant [
contraceptive counseling should incorporate assessment of risks
and use of the WHO Medical Eligibility Criteria (MEC)
for Contraceptive Use (http://www.who.int/reproductive
health/publications/family_planning/MEC-5/en/) or the
US MEC guidelines (https://www.cdc.gov/reproductive
However, given the lack of data, it is not possible to evaluate
the public health risks associated with lack of adherence
to these guidelines in at-risk midlife women.
Taken together, both the limited availability of data
about midlife women’s contraceptive practices and the
different patterns reported from around the globe
provoke many questions for further research. With respect
to the lack of data, one might inquire about the
assumptions that are responsible for this failure to include all
midlife women in national surveys or to enquire about
all types of contraception in cohort studies. Do
investigators assume that midlife women are not sexually
active?, that they are unable or unlikely to become
pregnant?, or that midlife women are solely concerned about
the amelioration of menopausal symptoms? Is it the case
that the focus of studies such as the NSFG has been on
family growth, with contraceptive use of interest only
because of its impact on fertility during the most fertile years?
Few pregnancies occur after age 45, thus it might seem
inefficient to sample women aged 46–55. Nonetheless,
there has been limited interest in defining in detail,
changes in fertility, reproductive aging, and pregnancy
experiences in women’s late reproductive years, or in
evaluating contraceptive needs/issues of women in the
waning years of fertility. The net result has been limited
data on midlife women’s health. Another possible
explanation is that epidemiologic cohort studies have
focused solely on understanding midlife women’s risk for
cancer and chronic disease and not considered women’s
fertility, sexuality or contraceptive needs during this phase
of the reproductive lifespan. A bias may exist about “too
few women” being affected by issues related to
contraception, hence a lack of interest in the contraception-related
health concerns of women at midlife. Whatever the cause
for the limited attention to contraceptive practices of
women in the midlife, there is reason to redouble research
efforts given the fact of continuing fertility of midlife
women, decisions by some midlife women to become
pregnant during their 40s and 50s alongside the
continuing problem of unintended pregnancy, the continuing
need for elective abortions and the increased risks of
maternal mortality at this life-stage.
Although women remain at risk of pregnancy until they
reach menopause, often until their mid-50s, information
about the prevalence of contraceptive use and women’s
contraceptive preferences is lacking. While pregnancy
rates decline substantially in the midlife, pregnancy
complications and risk of maternal death increase. National
data on contraceptive prevalence are needed from
women at least through age 54 years in both high and
low income countries, as well as data on availability of
reproductive services competent to address the health
concerns of women at this life-stage. In low income
countries as well as in the US, developing reproductive
health services for women during the late reproductive
years may be an important corollary to reducing the
continuing burden of maternal mortality.
SDH gratefully acknowledges use of the services and facilities of the Population
Studies Center at the University of Michigan, funded by NICHD Center Grant
Availability of data and materials
Not applicable, data used in this manuscript are public use data as cited in
the reference section.
SDH made substantial contributions to the conception of the manuscript,
oversaw the literature review and data analysis and had primary responsibility for
drafting the manuscript. JD conducted the literature review. MMH conducted
the data analysis. MFW contributed to drafting the manuscript. JD, MMH and
NFW contributed to the critical revision of the manuscript for important
intellectual content. All authors have read and approved the final manuscript.
Ethics approval and consent to participate
Consent for publication
SD Harlow is Editor In Chief of this journal and NF Woods is a member of
the Editorial Board. As per the journal policy, the peer review process and all
decisions regarding the manuscript were handled by an Associate Editor
from a different institution. SD Harlow and NF Woods were blinded to the
peer review. The other authors have no competing interests.
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