Contraceptive Alignment: A Descriptive Study of Concordance between Preferred and Actual Contraceptive Method Use

All authors meet the authorship requirements outlined by ICMJE.

The Committee for the Protection of Human Subjects at the University of California, Berkeley, and the Institutional Review Board at NORC at the University of Chicago approved the study protocol.

Study participants provided informed consent online prior to starting the online survey.

We utilized nationally representative data from the Person‐Centered Contraceptive Access Metrics project, a stakeholder‐engaged project that aimed to create novel population‐level metrics of contraceptive access; full details of the parent study can be found in an earlier publication (Gomez, Bennett, et al. 2024 ). Data were collected between January and March 2022 by NORC at the University of Chicago using the AmeriSpeak panel (NORC 2022 ). The panel is estimated to cover 97 percent of U.S. households and includes 54,001 noninstitutionalized members aged 13 and older from over 43,000 households (NORC 2022 ). Eligibility criteria for the study included being 15–44 years old; assigned female sex at birth; not known to be sterile; and able to complete the survey in English or Spanish. NORC invited all panel members meeting sex and age eligibility criteria to participate in the online, self‐administered survey. For panelists younger than 18, NORC first obtained parental consent before inviting them to participate in the survey. All study participants provided informed consent. Approximately 97 percent of screened and eligible panelists completed the survey. The survey took a median of 25 minutes to complete, and participants received compensation equivalent to $8 upon completion. The Committee for the Protection of Human Subjects at (The University of California, Berkeley) and the Institutional Review Board at NORC approved the study protocol. We created a measure to capture the alignment between individuals’ actual contraceptive use and their self‐identified preferred contraceptive method. This measure accounts for individuals’ contraceptive preferences, acknowledging that some individuals prefer not to use contraception, some may be contemplating starting or switching to a new method, or desire to immediately stop using their current method, and others may be unsure about their preferences, whether they are using contraception or not. To construct this variable, we compared participants’ preferred method use (Gomez, Bennett, et al. 2024 ) to their current contraceptive use. We define current contraceptive use as having used any method in the past month; respondents were provided an extensive list of contraceptive methods and were asked to indicate which methods they had used ever and in the last month. Respondents could indicate current use of multiple methods. Contraceptive use‐preference alignment was then determined using data from two survey questions: “Is there a method of birth control that you would like to use but are not currently using?” Responses included “yes,” “no,” and “not sure.” For each of their current methods, we asked current users, “Do you want to stop using [current method(s)] in the next year?” If respondents indicated they wanted to discontinue use of any of their current methods, they were asked if they wanted to stop using those methods “as soon as possible” (ASAP). “Is there a method of birth control that you would like to use but are not currently using?” Responses included “yes,” “no,” and “not sure.” For each of their current methods, we asked current users, “Do you want to stop using [current method(s)] in the next year?” If respondents indicated they wanted to discontinue use of any of their current methods, they were asked if they wanted to stop using those methods “as soon as possible” (ASAP). Classification into the categories of contraceptive alignment was dependent on the configuration between current contraceptive use, method preference, and desire to stop using any current method ASAP. Categories of alignment between actual and preferred contraceptive method use (hereinafter referred to as contraceptive alignment) included: (1) aligned and (2) not aligned/unsure. Our goal was to determine alignment, and anything other than alignment (misaligned or uncertain); therefore, the “not aligned” category does not equate to misaligned but rather a status other than aligned. We chose this approach based on the utility of binary metrics compared to multi‐category ones, and because anyone falling outside of the aligned category could be considered as needing support regarding their contraceptive use. Contraceptive alignment was determined separately for contraceptive users and nonusers (Figure  1 ). For contraceptive users, those categorized as “aligned” were using their preferred method, meaning they did not want to use a different method, use no contraception, or stop using any of their current methods ASAP. All other contraceptive users were categorized as “not aligned/unsure,” which included those who preferred to use a method they were not currently using or no method, or indicated that they were not sure if they wanted to use a method they were not using. Additionally, we classified contraceptive users who wanted to stop their method(s) ASAP as “not aligned/unsure,” as we could not confirm that they were using their preferred method. For multiple method users, we considered the preferred method mix; if, for example, a respondent wanted to discontinue use of one of their methods ASAP or preferred any method they were not currently using, they were categorized as “not aligned/unsure.” Among those not using contraception, we categorized individuals who did not indicate interest in using contraception as “aligned.” Those categorized as “not aligned/unsure” included current nonusers who indicated that they would like to use contraception or who were not sure if they wanted to use contraception. Contraceptive alignment categories We also used key sociodemographic and sexual and reproductive health variables in analyses, including age, race/ethnicity, relationship status (married, engaged, or in another serious relationship; in another type of relationship; or not in a relationship), income, educational attainment, ever having been pregnant, contraceptive methods ever used, and contraceptive self‐efficacy, which we measured using two questions (confidence in ability to obtain contraception and feeling one has enough information to make decisions about contraception; Schulte et al., 2025 ). Among contraceptive users, we describe contraceptive methods currently used, reasons for using contraception, and reasons for choosing a specific method. Individuals using multiple contraceptive methods were asked about reasons for using and choosing each of their methods. We report on whether respondents felt their current contraceptive method(s) was/were fully meeting their needs; for those using multiple contraceptive methods, this reflects whether respondents indicate their method mix as a whole was meeting their needs. For respondents not using contraception, we examined reasons for nonuse. A total of 3,059 individuals completed the survey. The analytic sample includes 3,044 individuals with data for actual and preferred contraceptive method use, including 2,079 current contraceptive users and 965 current nonusers (unweighted n s). We describe contraceptive alignment for the full sample. We conducted bivariate analyses of (1) key sociodemographic and (2) reproductive health characteristics by contraceptive alignment for the full sample; (3) methods used and reasons for using contraception and specific methods, among contraceptive users; and (4) reasons for not currently using contraception. For all descriptive analyses, we used Rao–Scott corrected chi‐square tests to account for the use of weighted data (Rao and Scott 1984 ). We conducted all analyses using Stata statistical analysis software (version 18.0) using the svy commands for weighting and complex survey design (StataCorp 2021 ). NORC constructed survey weights to account for differences between the study sample and the U.S. population on key demographic characteristics, including age, education, race/ethnicity, marital status, and number of children in the household. All reported n s are unweighted, and proportions are weighted.

Table  1 presents sociodemographic and reproductive health characteristics for the full sample. More than half (52.8 percent) of participants identified as white, 21.2 percent identified as Latinx/Hispanic, and 15.0 percent identified as Black. Over three‐quarters of the sample (78.3 percent) were between ages 15 and 34. Nearly half (49.6 percent) of participants were in a serious relationship, and 38.7 percent were parents. Participants were evenly distributed across education levels, a majority (65.6 percent) of the sample had private insurance, and about two‐thirds (68.0 percent) had an annual household income of $75,000 or less. Sociodemographic and reproductive health characteristics of contraceptive users and nonusers in a 2022 U.S. sample (unweighted N  = 3,044) Two‐thirds (65.8 percent) of participants were using contraception at the time of the survey, and most (81.5 percent) had ever had penile‐vaginal sex. Nearly half (45.0 percent) of participants had ever been pregnant. Most participants felt somewhat (39.3 percent) or very confident (54.6 percent) in their ability to obtain a desired contraceptive method, and 73.3 percent felt they had enough information to make decisions about contraception. Among the full sample, 87.4 percent had ever used contraception; the most common contraceptive methods ever used included condoms (76.4 percent), oral contraceptive pills (67.8 percent), and withdrawal (i.e., coitus interruptus; 67.0 percent). Overall, we classified two‐thirds of participants (62.2 percent) as having contraceptive alignment, while 37.8 percent were classified as not aligned/unsure. Among those classified as not aligned/unsure, 16.4 percent were uncertain about their contraceptive preferences (results not shown). Table  2 shows sociodemographic and reproductive health characteristics by contraceptive alignment category, stratified by contraceptive use/nonuse. Among contraceptive users, 64.1 percent were aligned, and 35.9 percent were not aligned/unsure. Contraceptive users who expressed contraceptive self‐efficacy (i.e., confidence in their ability to obtain a desired contraceptive method and/or feeling they have enough information to make decisions about contraception) were more commonly classified as aligned compared to those who did not; nearly three‐quarters (72.3 percent) of those who felt very confident in their ability to obtain contraception were classified as aligned, compared to 55.5 percent of those who were somewhat confident, and 29.2 percent who were not confident ( p  < 0.001). Similarly, more than half of contraceptive users (68.7 percent) who felt they had enough information to make decisions about contraception were classified as aligned compared to those who did not feel they had enough information (48.1 percent; p  < 0.001). Among contraceptive users, we found no statistically significant differences in contraceptive alignment by race/ethnicity, age, relationship status, parenting status, income, insurance coverage, or sexual and pregnancy history. Sociodemographic and reproductive health characteristics by contraceptive alignment among contraceptive users and nonusers in a 2022 U.S. sample (unweighted N  = 3,044) NOTE: Differences in categorical variables were assessed with corrected F statistics, based on Pearson chi‐square tests to account for complex survey design and weighting. Significant differences are bolded. Among nonusers of contraception, 58.5 percent were aligned and 41.5 percent were not aligned/unsure. Contraceptive alignment was higher among older nonusers (between 61.8 percent and 70.9 percent among 25–44‐year‐olds) compared to younger nonusers (48.1 percent of 18–24‐year‐olds and 53.6 percent of 15–17‐year‐olds; p  = 0.009). Additionally, contraceptive alignment was higher among nonusers who were in a serious relationship (68.6 percent) or another type of relationship (64.2 percent) compared to those who were not in a relationship (50.3 percent; p  < 0.001). Most contraceptive nonusers who felt very confident in their ability to obtain contraception (66.7 percent) were classified as aligned compared to 52.1 percent of those who were somewhat confident and 46.8 percent of those who were not confident ( p  < 0.001). Similarly, contraceptive alignment was higher among nonusers who felt they had enough information to make decisions about contraception (66.8 percent) compared to those who did not feel they had enough information (44.4 percent) or were unsure (47.9 percent; p  < 0.001). For contraceptive nonusers, we found no statistically significant differences in alignment by race/ethnicity, income, level of education, and insurance coverage. Table  3 shows characteristics of contraceptive use among current contraceptive users. The most frequently used contraceptive methods in the last month included withdrawal (38.5 percent), oral contraceptive pills (31.6 percent), and condoms (27.0 percent). Reasons for using current contraceptive methods included pregnancy prevention (90.4 percent), to regulate menstrual cycle (36.5 percent), to alleviate cramps or painful periods (23.2 percent), and to protect against sexually transmitted infections (STIs; 17.5 percent). A smaller proportion of contraceptive users reported using contraception to manage acne (9.4 percent), to relieve mood swings (8.7 percent), and to manage medical conditions such as endometriosis and polycystic ovary syndrome (7.5 percent). Common reasons for selecting current methods included convenience or availability at the place they obtain contraception (67.1 percent), ease of use (60.0 percent), affordability (e.g., covered by insurance or free; 55.8 percent), and lack of side effects (51.7 percent). Over a third (35.4 percent) of contraceptive users were using more than one method; commonly reported reasons for multiple method use included additional protection against pregnancy (50.9 percent), use of different methods for different reasons (31.3 percent), and dual protection against STIs and pregnancy (19.6 percent). The majority (70.2 percent) of contraceptive users reported their method(s) were fully meeting their needs. Characteristics of contraceptive use among contraceptive users in a 2022 U.S. sample (unweighted n  = 2,079) NOTE: Some sample sizes vary due to missingness or analyses among subsamples (e.g., multiple method users). a Only asked of those using methods without hormones. b Only asked of those not using internal methods, like the IUD and implant. c Only asked of those using more than one method. Table  4 presents characteristics of contraceptive use by contraceptive alignment categories among contraceptive users; only statistically significant results are shown. Contraceptive alignment was higher among those who used a hormonal intrauterine device (IUD) as their current method of contraception (75.5 percent) compared to those who did not (62.2 percent; p  = 0.002), as well as those who used a partner's vasectomy (88.3 percent), compared to those not reporting use of vasectomy (62.5 percent, p  < 0.001). Contraceptive alignment was lower among those who used emergency contraception in the last month (29.5 percent) compared to those who did not report emergency contraceptive use (64.8 percent, p  < 0.001). Notably, contraceptive alignment was lower among those who selected a current method after they could not obtain their desired method (14.7 percent) compared to those who did not report this reason for current method use (65.8 percent; p  < 0.001). Additionally, contraceptive alignment was lower among those who were using multiple contraceptive methods (55.4 percent) compared to those using only one method (68.7 percent; p  < 0.001). Lastly, contraceptive alignment was higher among those who reported their needs were fully being met by their current method(s) (74.4 percent), compared to those who reported their needs were not fully met (42.8 percent; p  < 0.001). Selected characteristics of contraceptive use by contraceptive alignment in a 2022 U.S. sample (unweighted n  = 2,079) NOTE: Differences in categorical variables were assessed with corrected F statistics, based on Pearson chi‐square tests, to account for complex survey design and weighting. Analyses included all variables presented in Table  3 ; only statistically significant results are shown. Table  5 presents reasons for not currently using contraception among those not using contraception at the time of the survey. The most common reasons for not using contraception included not currently engaging in sex that could result in pregnancy (23.4 percent), not having sex often (13.7 percent), wanting to become pregnant (11.5 percent), and concerns about side effects (10.7 percent). A small proportion of participants also reported not using contraception because they did not mind if they got pregnant (9.2 percent), were concerned about the safety of birth control (7.0 percent), or did not believe they could get pregnant (4.5 percent). Table  6 presents characteristics of contraceptive nonuse by contraceptive alignment; only statistically significant results are shown. Contraceptive alignment was lower among nonusers who reported they were not using contraception because they were not having sex often (43.1 percent) compared to those who did not report this reason for not using contraception (61.0 percent, p  = 0.005). In contrast, contraceptive alignment was higher among nonusers who did not mind if they became pregnant (83.4 percent) compared to those who did not report this reason for not using contraception (56.0 percent; p  < 0.001); it was also higher among nonusers who wanted to become pregnant (73.6 percent) compared to those who did not report this reason for not using contraception (56.5 percent; p  = 0.005). Characteristics of contraceptive nonuse in a 2022 U.S. sample (unweighted n  = 965) Selected characteristics of contraceptive nonuse by alignment categories in a 2022 U.S. sample (unweighted n  = 965) NOTE: Differences in categorical variables were assessed with corrected F statistics, based on Pearson chi‐square tests, to account for complex survey design and weighting. Analyses included all reasons for not currently using contraception presented in Table  5 ; only statistically significant results are shown.

Accounting for contraceptive preferences is critical to providing person‐centered contraceptive care and supporting reproductive autonomy. Our findings suggest that individuals’ contraceptive preferences and use are not always aligned, and that some may wish to avoid using contraception altogether. Further, utilizing nuanced metrics, like contraceptive alignment, may help ensure that public resources are used effectively and that family planning efforts are directed at those who truly need them.

In this study, we describe alignment between preferred and actual contraceptive method use among a national U.S. sample of individuals assigned female sex at birth. Overall, most respondents were classified as having contraceptive alignment. However, nearly a quarter were not classified as aligned, meaning that they were contraceptive users not using their preferred method or who wanted to stop using their method ASAP, nonusers who wanted to use a contraceptive method, or they were uncertain about their contraceptive preferences. Our findings reveal nuanced relationships between contraceptive use, preferences, and personal characteristics not apparent by looking at contraceptive use alone. For example, our finding that over half of contraceptive nonusers were classified as having contraceptive alignment supports existing literature showing that some individuals, regardless of pregnancy preference or intention, do not want to use contraception for a variety of reasons (Frederiksen and Ahrens 2020 ; Moreira et al. 2019 ; Sedgh and Hussain 2014 ; Senderowicz et al. 2023 ). Additionally, our finding that, among contraceptive nonusers, contraceptive alignment differed by age and relationship status suggests that as individuals get older or transition into serious relationships, they may be better able to fulfill their preference for not using contraception. This finding also suggests that young people may require additional or unique support in identifying and/or accessing a method that meets their needs, as a notable proportion of young contraceptive nonusers were classified as not aligned/unsure. Our conceptualization of contraceptive alignment allowed us to identify individuals who may not have their contraceptive needs met and who would be missed by conventional measures, particularly among current users. For example, contraceptive alignment was significantly lower among those who reported using their current contraceptive method because they were unable to obtain a method they originally wanted, compared to those who did not choose their method for this reason. Importantly, conventional metrics may classify these individuals as having their contraceptive needs met due to their current use of a contraceptive method, masking the access issues that undergird lack of contraceptive alignment (Frost et al. 2026 ; Gomez, Reed, et al. 2024 ). While limited, research suggests that using a contraceptive method that is not aligned with one's preferences may lead to method switching or discontinuation (Burke, Thaxton, and Potter 2021 ; Burke and Potter 2023 ; Ela et al. 2022 ), leaving individuals at a greater risk for experiencing pregnancy when one may not be desired. Identifying an absence of contraceptive alignment among users is also particularly important in the context of long‐standing threats to reproductive autonomy in the United States, where women and birthing people of color, as well as under‐resourced individuals, report pressure to use certain forms of contraception (Biggs et al. 2019 ; Eeckhaut and Hara 2023 ; Gomez and Wapman 2017 ; Brandi et al. 2018 ) and barriers to discontinuing provider‐controlled methods (Fox et al. 2024 ; Hall et al. 2024 ; Kaneshiro et al. 2020 ). These experiences impede individuals from making informed decisions about contraceptive use and constitute barriers to reproductive autonomy. Therefore, identifying a lack of contraceptive alignment for those using contraception may be helpful in directing resources toward individuals who require additional support to meet their contraceptive needs and preferences, thereby supporting their reproductive autonomy. We also identified a relationship between contraceptive self‐efficacy and contraceptive alignment, suggesting the importance of contraceptive self‐efficacy for reproductive health and well‐being (Schulte et al. 2025 ). In our study, contraceptive alignment was higher among both contraceptive users and nonusers who reported higher contraceptive self‐efficacy (i.e., feeling confident they can obtain a desired contraceptive method when they want it, and that they have enough information to make decisions about contraception) compared to those with lower contraceptive self‐efficacy. While there is research exploring contraceptive self‐efficacy by demographic characteristics, such as gender, socioeconomic status, and race (Callegari et al. 2017 ; Gray and and Fisher 2021 ; Hamidi et al. 2018 ; Longmore et al. 2003 ; Schulte et al. 2025 ), less is known about the mechanisms through which individuals attain contraceptive self‐efficacy, including what influences their perceptions of their ability to acquire and use contraception on their own terms. Given that contraceptive self‐efficacy may support contraceptive alignment, supporting individuals in developing contraceptive self‐efficacy is critical to promoting sexual and reproductive health and well‐being. We also found lower contraceptive alignment among individuals who were using multiple contraceptive methods compared to those who were using only one method. This may be due to multiple method users having additional needs for contraception beyond pregnancy prevention, which may lead them to use more methods than desired to meet those needs. More research is needed to understand if and how using multiple contraceptive methods impacts contraceptive alignment. Public health efforts often focus on increasing access to and uptake of contraception as a means to improve population‐level maternal and reproductive health. However, our finding that more than half of contraceptive nonusers were classified as having contraceptive alignment suggests their preference for contraceptive nonuse was fulfilled. In the context of reproductive autonomy, this outcome is a positive one, given these individuals’ self‐reported preference for not using contraception and their actualization of that preference. Further, we found that contraceptive alignment was higher among nonusers of contraception who did not mind if they became pregnant compared to those who did not choose this reason for not using contraception. Ample research finds that many individuals do not necessarily plan or “try” for pregnancy but instead may exhibit an openness or acceptability toward a pregnancy if one were to occur (Arteaga, Caton, and Gomez 2019 ; Arteaga et al. 2020 ; Borrero et al. 2015 ; Gomez et al. 2018 , 2021 ; Manze et al. 2021 ; McQuillan, Greil, and Shreffler 2011 ; Kendall et al. 2005 ). Our findings suggest that those who are open to a pregnancy but not necessarily trying for one may have less of a self‐identified need for contraception; efforts to increase contraceptive use among these individuals would be mistargeted. By considering contraceptive nonuse in the context of individuals’ preferences, we can clearly interpret contraceptive nonuse as a successful reproductive health outcome and indicator of reproductive autonomy, rather than a failure. The survey sample did not include individuals who personally used permanent contraception (e.g., tubal ligation), were not assigned female sex at birth, and were infecund, limiting the generalizability of our findings to these groups. Our metric of contraceptive alignment is novel and innovative but is limited, as all point‐in‐time metrics are, by the dynamic and complex nature of the constructs under study. For the subset of contraceptive users who did not report wanting to use another or no method but who did report wanting to stop their method ASAP, we are not able to confirm whether their preferences were being met at the time of the survey. For example, they could have been using the method they preferred at the time of the survey but also knew they wanted to stop ASAP because they wanted to become pregnant or their partner was getting a vasectomy. We are also limited by the definition of “current method use” as in the prior month. While this common measurement approach is necessary to capture the use of coital‐based methods, it also limits our ability to know what methods were being used at the exact time of the survey. Additionally, using two questions to measure contraceptive self‐efficacy may not be sufficient to capture the complexity inherent in this important construct. Qualitative methods would likely be helpful in placing these findings within the context of respondents’ lives, which likely influences their contraceptive use and preferences. Lastly, analysis of contraceptive alignment among specific subgroups of interest (e.g., subgroups within the two alignment categories) was limited by small sample sizes. Contraceptive alignment has important implications for reproductive justice, especially regarding contraceptive nonuse. According to the tenets of reproductive justice, which advocate for full reproductive self‐determination (Ross and Solinger 2017 ), choosing not to contracept is a fundamental human right; measures of contraceptive alignment may help identify those who do not prefer to use contraception and support them in making this choice. Additionally, utilizing our metric of contraceptive alignment, rather than the traditional, assumption‐laden metric of unmet need, may support a reframing and de‐stigmatization of contraceptive nonuse for those who do not want to use contraception, even if they wish to avoid pregnancy. Indeed, acknowledging that contraceptive nonuse may reflect contraceptive alignment can help reframe nonuse as a successful person‐centered outcome and uplift reproductive autonomy. While prioritizing contraceptive preferences is a promising step toward reproductive justice, we must also be attuned to the context in which individuals are formulating their preferences. For example, it is highly likely that some individuals’ preferences are shaped by access (real or perceived) to specific contraceptive methods, while others’ preferences may be influenced by the information they receive via social media and peers. Consequently, contraceptive preferences are dynamic and may be difficult to fully realize due to structural and policy contexts that limit reproductive choice and undermine reproductive autonomy. Even so, our analysis indicates that considering contraceptive preferences, which is fundamental to providing person‐centered contraceptive care, is critical to supporting individuals in meeting their reproductive health needs (Dehlendorf et al. 2021 , 2023 ). Family planning providers should consider incorporating discussions of contraceptive preference‐use alignment into counseling visits to ensure they are providing patient‐centered care and supporting reproductive autonomy. This study also has implications for reproductive health policy. Our findings echo existing research noting the limitations of conventional measures of contraceptive need, specifically regarding misclassification of contraceptive need due to ignoring contraceptive preferences. Scholars have documented the population‐ and individual‐level consequences of this misclassification, including the misuse of public resources and misdirected public health efforts to increase contraceptive use, as well as constrained reproductive autonomy (Karra 2022 ; Rominski and Stephenson 2019 ; Senderowicz et al. 2023 ; Senderowicz and Maloney 2022 ; Speizer, Bremner, and Farid 2022 ; Gomez, Bennett, et al. 2024 ; Gomez, Reed, et al. 2024 ). Reconceptualizing contraceptive need as contraceptive alignment has the potential to direct public health resources and efforts toward individuals who actually want to use contraception, potentially saving costs, which is especially pertinent in the context of austerity measures being implemented by the current U.S. administration. Additionally, prioritizing contraceptive alignment in healthcare settings is in line with person‐centered contraceptive care, which supports reproductive autonomy (Dehlendorf et al. 2021 ; Holt et al. 2020 ).

Reproductive health researchers, advocates, and providers have highlighted the pitfalls of traditional conceptualizations of reproductive health indicators, noting the potential for existing measures to misclassify individuals’ reproductive health needs, exclude self‐identified preferences, and infringe upon reproductive autonomy (Aiken et al. 2016 ; Borrero et al. 2015 ; Gomez et al. 2019 ; Mumford et al. 2016 ; Senderowicz and Maloney 2022 ; Vincent et al. 2025 ; Gomez, Bennett, et al. 2024 ; Frost et al. 2026 ; Holt et al. 2023 ). For example, scholars have questioned the utility of conventional measures of “unmet need for contraception,” arguing that these measures assume everyone who is avoiding pregnancy should be using contraception and that those who are using contraception are satisfied with their method and, therefore, have their needs met (Frost et al. 2026 ; Senderowicz et al. 2023 ; Senderowicz and Maloney 2022 ; Vincent et al. 2025 ; Gomez, Reed, et al. 2024 ; Holt et al. 2023 ). However, existing research indicates that individuals may use multiple contraceptive methods during their reproductive trajectories, or choose not to use contraception at all, despite wanting to avoid pregnancy (Downey et al. 2017 ; Gomez et al. 2019 ; Swiatlo et al. 2023 ; Gomez, Bennett, et al. 2024 ; Arteaga and Gomez 2016 ). Additionally, research suggests that some individuals may have a preference to use contraception for reasons beyond pregnancy prevention, particularly hormonal methods, which can often have medical benefits, such as alleviating painful periods or symptoms related to polycystic ovary syndrome, now known as polyendocrine metabolic ovary syndrome (Jones 2011 ; Godfrey et al. 2011 ). This lack of attention to users’ self‐defined preferences can lead to misclassification of individuals as needing contraception when, in reality, they may not, and miss individuals who wish to use contraception but may appear not to need it due to lack of sexual activity (Speizer, Bremner, and Farid 2022 ; Karra 2022 ; Rominski and Stephenson 2019 ; Senderowicz et al. 2023 ; Senderowicz and Maloney 2022 ; Gomez, Reed, et al. 2024 ). Making assumptions about who does and does not need contraception has important population‐ and individual‐level implications. Conventional population‐level measures of contraceptive need historically include people with no self‐defined need for contraception and exclude others who do have a self‐defined need, leading to incorrect estimates of the population in need of contraception (Frost et al. 2026 ; Senderowicz and Maloney 2022 ; Gomez, Reed, et al. 2024 ). Because conventional measures of contraceptive need are used as a tool to inform policy and programmatic efforts to expand, direct, and monitor contraceptive access, incorrect estimates can lead to ineffective interventions and misuse of limited resources allocated to reproductive health initiatives. Importantly, people of color may be most impacted by the consequences of misclassification of contraceptive need as, historically, they have been the targets of efforts to promote increased contraceptive use, contributing to inequities in sexual and reproductive health and well‐being (Barnett et al. 2022 ; Eeckhaut and Hara 2023 ; Foster 2020 ; Gutierrez 2008 ; Ho et al. 2022 ; McLemore et al. 2018 ; Roberts 1999 ; Gomez and Wapman 2017 ). Conventional measures of contraceptive need may also undermine reproductive autonomy due to their reliance on researcher‐defined conceptualizations of need, which focus narrowly on contraceptive use as a proxy for availability and demand, rather than individuals’ preferences. To foreground person‐centeredness in measures of contraceptive use and access, researchers have begun assessing concordance or alignment between preferred and actual contraceptive method use, as well as the consequences of misalignment between the two (Senderowicz and Maloney 2022 ; Vincent et al. 2025 ; Gomez, Bennett, et al. 2024 ; Gomez, Reed, et al. 2024 ; Holt et al. 2023 ). For example, one U.S. study of nonsterile 15–44‐year‐olds assigned female sex at birth found that 25 percent of individuals who were using or wanted to use contraception were not using their preferred method (Gomez, Bennett, et al. 2024 ), in line with previous research in other settings (Chakraborty et al. 2021 ; He et al. 2017 ; Vincent et al. 2025 ). Notably, there was a significant association between having received person‐centered contraceptive counseling in the past and use of preferred contraceptive method (Gomez, Bennett, et al. 2024 ). Another study of 1,700 postpartum Texans who did not want to become pregnant in the next two years found that alignment between preferred contraceptive method and actual use was associated with half the likelihood of becoming pregnant and having a child within 21 months of their previous birth (Potter et al. 2025 ). In this study, we expand upon our prior work, in which we developed a novel metric of preferred contraceptive method use and compared it to conventional metrics of contraceptive need among users and prospective users of contraception (Gomez, Bennett, et al. 2024 ). Here, we build on that metric and present a closely related metric of contraceptive alignment to describe alignment between actual and preferred contraceptive method use/nonuse among a nationally representative U.S. sample of individuals assigned female sex at birth. Additionally, we describe the relationship between sociodemographic and sexual and reproductive health characteristics and contraceptive alignment. In contrast to our prior work, which included a sample of only current and prospective users of contraception, our analytic sample includes all individuals to identify and describe those who are not using and do not want to use contraception and therefore should not be considered “at need” for contraception. Notably, our work shares similarities with Vincent and colleagues’ ( 2025 ) recent work on “contraceptive concordance,” in which they compare individuals’ current actual contraceptive use to their hypothetical feelings around method (dis)continuation or switching (among users) and initiation (among nonusers), as well as Holt and colleagues’ ( 2023 ) measure of preference‐aligned fertility management (PFM). Our metric differs in three important ways: (1) we classify contraceptive users who want to switch methods as not having alignment between their actual and preferred contraceptive method use (i.e., they are using a certain method when they prefer to use another method), while Vincent and colleagues ( 2025 ) classify these individuals as concordant (they want to be using contraception and are using it); (2) we compare use of specific contraceptive methods to actual current desire for method discontinuation, switching, or initiation, rather than a hypothetical desire for such as in Vincent and colleagues’ metric; and (3) we capture a range of contraceptive needs beyond pregnancy prevention, as opposed to the PFM metric, which utilizes questions about contraceptive use specifically for avoiding pregnancy. Importantly, research suggests that individuals may want to switch their contraceptive method for a variety of reasons, including dissatisfaction with their current method due to usability, side effects, reliability, or other considerations (J. J. Frost, Singh, and Finer 2007 ; Steinberg et al. 2021 ; Wellings et al. 2015 ), suggesting that they may need an alternative method of contraception that better aligns with their preference. Compared to contraceptive concordance, our metric offers an alternative to capture alignment between contraceptive method preferences and actual use with greater nuance.

The authors have no conflicts of interest to disclose.