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--> Summary Unintended pregnancy is both frequent and widespread in the United States. The most recent estimate is that almost 60 percent of all pregnancies are unintended, either mistimed or unwanted altogether1—a percentage higher than that found in several other Western democracies. Unintended pregnancy is not just a problem of teenagers or unmarried women or of poor women or minorities; it affects all segments of society. The consequences of unintended pregnancy are serious, imposing appreciable burdens on children, women, men, and families. A woman with an unintended pregnancy is less likely to seek early prenatal care and is more likely to expose the fetus to harmful substances (such as tobacco or alcohol). The child of an unwanted conception especially (as distinct from a mistimed one) is at greater risk of being born at low birthweight, of dying in its first year of life, of being abused, and of not receiving sufficient resources for healthy development. The mother may be at greater risk of depression and of physical abuse herself, and her relationship with her partner is at greater risk of dissolution. Both mother and father may suffer economic hardship and may fail to achieve their educational and career goals. Such consequences undoubtedly impede the formation and maintenance of strong families. In addition, an unintended pregnancy is associated with a higher probability that the child will be born to a mother who is adolescent, unmarried, or over age 40—demographic attributes that themselves have important socioeconomic and 1 These terms have precise demographic meanings and are defined carefully in the body of the report.
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--> medical consequences for both children and parents. Pregnancy begun without planning and intent also means that individual women and couples are often not able to take full advantage of the growing field of preconception risk identification and management, nor of the rapidly expanding knowledge base regarding human genetics. Moreover, unintended pregnancy currently leads to approximately 1.5 million abortions in the United States annually, a ratio of about one abortion to every three live births. This ratio is two to four times higher than that in other Western democracies, in spite of the fact that access to abortion in those countries is often easier than in the United States. Reflecting the widespread occurrence of unintended pregnancy, abortions are obtained by women of all reproductive ages, by both married and unmarried women, and by women in all income categories. Of the 5.4 million pregnancies that were estimated to have occurred in 1987, about 3.1 million were unintended at the time of conception. Within this pool of unintended pregnancies, some 1.6 million ended in abortion and 1.5 million resulted in a live birth. Only 2.3 million pregnancies in that year were intended at the time of conception and resulted in a live birth. During the 1970s and early 1980s, the proportion of births that were unintended at the time of conception decreased. Between 1982 and 1988, however, this trend reversed and the proportion of births that were unintended at conception began increasing. This unfortunate trend appears to be continuing into the 1990s. In 1990, about 44 percent of all births were the result of unintended pregnancy;2 the proportion is close to 60 percent among women in poverty, 62 percent among black women, 73 percent among never-married women, and 86 percent among unmarried teenagers. Many factors help to explain the nation's high level of unintended pregnancy. Most obvious is the failure to use contraceptive methods carefully and consistently—or sometimes even at all—as well as actual technical failures of the methods themselves. Women and their partners relying on reversible means of contraception (about 21 million women) and those using no contraception at all, despite having no clear intent to become pregnant (about 4 million women), contribute roughly equally to the pool of unintended pregnancies. Many women and couples who are not seeking pregnancy move between these two groups, sometimes using contraception, sometimes not. Contraceptive use and unintended pregnancy are influenced by numerous factors: knowledge about contraceptive methods and reproductive health generally, individual skill in using contraception properly, a wide range of personal feelings and attitudes, varying patterns of sexual behavior, access to 2 The difference between the percentage of pregnancies that are unintended (close to 60 percent) and the percentage of births resulting from unintended pregnancies (about 44 percent) is due to the intervening occurrence of abortion.
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--> contraceptive methods themselves, cultural values regarding sexuality, religious and political preferences, racism and violence, the sexual saturation of the media, and others as well. The sheer number and complexity of these forces mean that no single or simple remedy is likely to ''solve" the unintended pregnancy problem, particularly because the interrelationships among all of these factors are not well understood. Nonetheless, the information reviewed in this report, past experience in the public health sector with addressing complex health and social problems, and common sense are all helpful in developing a plan of action to address this important national problem. Committee Recommendations The extent of unintended pregnancy and its serious consequences are poorly appreciated throughout the United States. Although considerable attention is now focused on teenage pregnancy and nonmarital childbearing, along with continuing controversy and even violence over abortion, the common link among all these issues—pregnancy that is unintended at the time of conception—is essentially invisible. The committee has concluded that reducing unintended pregnancy will require a new national understanding about this problem and a new consensus that pregnancy should be undertaken only with clear intent. Accordingly, the committee urges, first and foremost, that the nation adopt a new social norm: All pregnancies should be intended—that is, they should be consciously and clearly desired at the time of conception. This goal has three important attributes. First, it is directed to all Americans and does not target only one group. Second, it emphasizes personal choice and intent. And third, it speaks as much to planning for pregnancy as to avoiding unintended pregnancy. Bearing children and forming families are among the most significant and satisfying tasks of adult life, and it is in that context that encouraging intended pregnancy is so central. The U.S. Department of Health and Human Services, through its National Health Promotion and Disease Prevention Objectives, has urged that the proportion of all pregnancies that are unintended be reduced to 30 percent by the year 2000. The committee endorses this goal and stresses that it is a realistic one already reached by several other industrialized nations. Achieving this goal would mean, in absolute numbers, that there would be more than 200,000 fewer births each year that were unwanted at the time of conception, and about 800,000 fewer abortions annually as well.
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--> To begin the long process of building national consensus around this norm, the committee recommends a multifaceted, long-term campaign to (1) educate the public about the major social and public health burdens of unintended pregnancy and (2) stimulate a comprehensive set of activities at national, state, and local levels to reduce such pregnancies. It is essential that the campaign direct its messages to national leaders and major U.S. institutions, as well as to individual men and women. The problem of unintended pregnancy is as much one of public policies and institutional practices as it is one of individual behavior, and therefore the campaign should not try to reduce unintended pregnancies only by actions focused on individuals or couples. Although individuals clearly need increased attention and services, reducing unintended pregnancy will require that influential organizations and their leaders—corporate officers, legislators, media owners, and others of similar stature—address this problem as well. The campaign should also draw on the successful experience of other major efforts to address complicated public health problems, such as the national campaigns to reduce smoking, limit drunk driving, and increase the use of seat belts. The campaign should emphasize that reducing unintended pregnancy will ease many contemporary problems that are of such concern. Both teenage pregnancy and nonmarital childbearing would decline, and abortion in particular would be reduced dramatically. More generally, the lives of children, women, men, and their families, including those now mired in persistent poverty and welfare dependence, would be strengthened considerably by an increase in the proportion of pregnancies that are purposefully undertaken and consciously desired. The Campaign to Reduce Unintended Pregnancy The campaign to reduce unintended pregnancy should stress five core goals: 1. improve knowledge about contraception, unintended pregnancy, and reproductive health; 2. increase access to contraception; 3. explicitly address the major roles that feelings, attitudes, and motivation play in using contraception and avoiding unintended pregnancy; 4. develop and scrupulously evaluate a variety of local programs to reduce unintended pregnancy; and
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--> 5. stimulate research to (a) develop new contraceptive methods for both women and men, (b) answer important questions about how best to organize contraceptive services, and (c) understand more fully the determinants and antecedents of unintended pregnancy. In the balance of this summary, each of these five campaign goals is outlined in more detail. Campaign Goal 1: Improve knowledge about contraception, unintended pregnancy, and reproductive health. An important reason for inadequate contraceptive vigilance, and therefore unintended pregnancy, is that many Americans lack adequate knowledge about contraception and reproductive health generally. The fact that many people mistakenly believe that childbearing is less risky medically than using oral contraceptives is a sobering example of this problem. The resulting fears and misconceptions that stem from such erroneous beliefs can impede the careful, consistent use of contraception, which in turn contributes to the risk of unintended pregnancy. Accordingly, the campaign should include a series of information and education activities directed to women of all ages, not just adolescent girls, describing available contraceptive methods and highlighting, in particular, the common occurrence of unintended pregnancy among women age 20 and over, especially those over age 40 for whom an unintended pregnancy may carry particular medical risks. Activities should target boys and men as well, emphasizing their stake in avoiding unintended pregnancy, the contraceptive methods available to them, and how to support their partners' use of contraception. And both men and women need balanced, accurate information about the benefits and risks attached to specific contraceptive methods. Parents, families, and both religious and community institutions should be major sources of information and education about reproductive health and family planning, especially for young people, and they should be supported in serving this important function. In addition, U.S. school systems should continue developing comprehensive, age-appropriate programs of sex education that build on new research about effective content, timing, and teacher training for these courses. State laws and policies should be revised, where necessary, to allow and encourage such instruction. Information and education about contraception should include abstinence as one of many methods available to prevent pregnancy. And particularly in programs directed to adolescents, it is important to encourage and help young people resist precocious sexual involvement. Sexual intercourse should occur in
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--> the context of a major interpersonal commitment based on mutual consent and caring and on the exercise of personal responsibility, which includes taking steps to avoid both unintended pregnancy and sexually transmitted diseases (STDs). The electronic and print media should reinforce the material presented in schools and elsewhere, thereby helping to educate adults as well as school-aged children about contraception and reproductive health. The media should present accurate material on the benefits and risks of contraception and should broaden current messages about preventing STDs to include preventing unintended pregnancy as well. Media producers, advertisers, story writers, and others should also balance current entertainment programming so that, at a minimum, sexual activity is preceded by a mutual understanding of both partners regarding its possible consequences, and accompanied by contraception when appropriate. Similarly, advertising of contraceptive products and public service announcements regarding unintended pregnancy and contraception should be more plentiful. Campaign Goal 2: Increase access to contraception. Through a combination of financial and structural factors, the health care system in the United States makes access to prescription-based methods of contraception a complicated, sometimes expensive proposition. Private health insurance often does not cover contraceptive costs; the various restrictions on Medicaid eligibility make it an unreliable source of steady financing for contraception except for very poor women who already have a child; and the net decline in public investment in family planning services (especially those services supported by Title X of the Public Health Service Act), in the face of higher costs and sicker patients, may have decreased access to care for those who depend on publicly financed services, particularly adolescents and low-income women. Condoms, the most accessible form of contraception, provide valuable protection against STDs but must be accompanied by other contraceptive methods to afford maximum protection against unintended pregnancy. Unfortunately, other accessible nonprescription methods, such as foam and other spermicides, neither prevent the transmission of STDs nor offer the best protection against unintended pregnancy. The campaign to reduce unintended pregnancy should promote increased access to contraception generally, but especially to the more effective prescription-based methods that require contact with a health care professional. Financial barriers in particular should be reduced by (1) increasing the proportion of all health insurance policies that cover contraceptive services and supplies, including both male and female sterilization, with no copayments or other cost-sharing requirements, as for other selected preventive health services; (2) extending Medicaid coverage for all postpartum women for 2 years following
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--> childbirth for contraceptive services, including sterilization; and (3) continuing to provide public funding—federal, state, and local—for comprehensive contraceptive services, especially for those low-income women and adolescents who face major financial barriers in securing such care. This last point speaks to the major role that such public financing programs as Title X and Medicaid have played in helping millions of people secure contraception. Although evaluation research has not yet defined the precise effects of these programs on unintended pregnancy, there is no question that they help to finance contraceptive services for many women (and some men), the principal means by which unintended pregnancy is prevented. Accordingly, it is essential that such public investment be maintained. In addition, foundations and government should fund high-quality evaluation studies of the impact that both Title X and Medicaid have on unintended pregnancy and related outcomes. Without better data on the effects of these and other publicly funded programs active in the area of reproductive health, such programs remain particularly vulnerable to attack, and it is difficult to know how best to strengthen them. As another way to increase access to contraceptive services, the campaign should also broaden the range of health professionals and institutions that promote and provide methods of birth control. Campaign leaders, for example, should work with medical educators to revise the training curricula of a wide variety of health professionals (physicians, nurses, and others) to increase their competence in reproductive health and contraceptive counseling for both males and females and, where appropriate, in actually providing contraceptive methods. The campaign should also encourage those who provide social work, employment training, educational counseling, and other social services to talk with their clients about the benefits of pregnancy planning and how to do so. Campaign Goal 3: Explicitly address the major roles that feelings, attitudes, and motivation play in using contraception and avoiding unintended pregnancy. Although increasing knowledge about and access to contraception (Campaign Goals 1 and 2) are important first steps, they are not enough. The campaign to reduce unintended pregnancy must also address the fact that the personal attitudes, motivation, and feelings of individuals and couples clearly affect contraceptive use and therefore the risk of unintended pregnancy. Similarly, partner preferences, and particularly the quality of a couple's relationship, are also important influences, as is overall comfort with sexuality; and feelings about specific contraceptives can affect an individual's choice of method and the success with which it is used as well. In truth, avoiding unintended pregnancy can be hard to do, requiring specific skills and steady dedication over time, often from both partners. The
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--> strong, consistent motivation that many forms of reversible contraception require is typically fueled by a view of life in which pregnancy and childbearing are seen, at a given point in time, as less attractive than other alternatives. Being pregnant and bearing a child often bring significant psychological and social rewards, and there must be good reason to forego them. In order to address feelings, attitudes, and motivation more directly, contraceptive services should be sufficiently well funded (through adequate reimbursement rates and/or public sector support) to include extensive counseling—of both partners, whenever possible—about the skills and commitment needed to use contraception successfully. Similarly, school curricula and programs that train health and social services professionals in reproductive health should include ample material about the skills that contraception requires and about the influence of personal factors on successful contraceptive use, along with more conventional information about reproductive physiology and contraceptive technology. The influence of motivation in pregnancy prevention also underscores the importance of longer-acting, coitus-independent methods of contraception (e.g. hormonal implants and injectables and, when appropriate, intrauterine devices) because they require only minimal attention once the method is established. Although few women and couples rely on these methods, their long-term potential for reducing unintended pregnancy is great. When offered with careful counseling and meticulous attention to informed consent, these methods constitute an important component of the contraceptive choices available in this country. They do not, however, protect against the transmission of STDs, which requires that condoms be used also. On a broader level, policy leaders need to confront the notion that, especially for those most impoverished, reducing unintended pregnancy may well require that more compelling alternatives than pregnancy and childbearing be available. Such alternatives include better schools, realistic expectations that a high school diploma will lead to an adequate income, and jobs that are available and satisfying. Increasing knowledge about contraception and improving access to it as well may not be enough to achieve major reductions in unintended pregnancy when the surrounding environment offers few incentives to postpone childbearing. This comment is not meant to suggest that unless poverty is eliminated unintended pregnancy cannot be reduced. The point is rather than, in the poorest communities especially, only modest reductions in unintended pregnancy will likely be achieved by the usual prescription of "more education, information, and services." In this context, it is important to note that research findings do not support the popular notion that welfare payments (i.e., AFDC) and other income transfer programs exert an important influence on non-marital childbearing.
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--> Campaign Goal 4: Develop and scrupulously evaluate a variety of local programs to reduce unintended pregnancy. Little is known about effective programming at the local level to reduce unintended pregnancy. Accordingly, the campaign to reduce unintended pregnancy should encourage public and private funders to support a series of new research and demonstration programs in this field that are designed to answer a series of clearly articulated questions, evaluated very carefully, and replicated when promising results emerge. The focus and design of these new programs should be based, at a minimum, on a careful assessment of 23 programs identified by the committee whose effects on specific fertility measures related to unintended pregnancy have been carefully assessed. Evaluation data from these programs support several broad conclusions: (1) even those few programs showing positive effects report only small gains, which demonstrates how difficult it can be to achieve major decreases in unintended pregnancy; (2) because most evaluated programs target adolescents, especially adolescent girls, knowledge about how to reduce unintended pregnancy among adult women and their partners is exceedingly limited; (3) there is insufficient evidence to determine if "abstinence-only" programs for young adolescents are effective, but encouraging results are being reported by programs with more complex messages stressing both abstinence and contraceptive use once sexual activity has begun; (4) few evaluated programs actually provide contraceptive supplies; and (5) only mixed success has been reported from programs trying to prevent rapid repeat pregnancies among adolescents and young women. The new research and demonstration programs should reflect several additional themes as well. Unintended pregnancies derive in roughly equal proportions from couples who report some use of contraception, however imperfect, and from couples who report no use of contraception at all at the time of conception. Although many individuals move back and forth between these two states over time, it may nonetheless be useful to develop specific strategies for each group, especially for the very high-risk group of nonusers. Another theme that should shape these research and demonstration programs is the need to develop and test out new ways to involve men more deeply in the issue of pregnancy prevention and contraception. And finally, these programs should explore how to build community support for contraception. Although contraceptive use is ultimately a personal matter, community values and the surrounding culture clearly shape the actions of individuals and couples. Accordingly, at least some demonstration programs should target both the community and the individual, and some might also work exclusively at the community level.
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--> Campaign Goal 5: Stimulate research to (a) develop new contraceptive methods for both women and men, (b) answer important questions about how best to organize contraceptive services, and (c) understand more fully the determinants and antecedents of unintended pregnancy. The need to develop new contraceptive methods for both men and women is compelling. One of the reasons that unintended pregnancy continues to occur is that the available contraceptive methods are not always well suited to personal preferences or to various ages and life stages. Particularly glaring is the lack of effective male methods of reversible contraception other than the condom. There is also a clear need for more health services research in the field of pregnancy prevention. For example, little is known about how access to prescription-based methods of contraception is enhanced or restricted by the many managed care arrangements now shaping health services. Finally, there is a pressing need for more interdisciplinary research to understand the complex relationships among the cultural, economic, social, biological, and psychological factors that lie behind widely varying patterns of contraceptive use and therefore unintended pregnancy. Research on personal feelings, attitudes, and beliefs as they affect contraceptive use, and especially several recent ethnographic investigations of motivation, offer particularly intriguing explanations for the observed phenomena. Careful work is needed to integrate these ideas with the more traditional explanations of unintended pregnancy, such as inaccessible contraceptive services or insufficient knowledge about how to prevent pregnancy. Research is also needed on factors outside of individuals (such as the impact of media messages on the contraceptive behavior of individuals), on factors within couples (such as the relative power and influence of women and men in decisions to use or not use particular methods of contraception), and on the combination of individual, couple, and environmental factors considered together. In all such multivariate research, it will be important to study the determinants of sexual behavior as well as contraceptive use, inasmuch as the two are often intimately connected and may jointly influence the risk of unintended pregnancy. Campaign Leadership Progress toward achieving the five campaign goals outlined above would be enhanced by the existence of a readily identifiable, public–private consortium whose mission is to lead the recommended campaign. Funding and leadership of the consortium should be provided by private foundations, given their proven capacity to draw many disparate groups together around a shared concern. Members of this consortium should be recruited from numerous sectors, both public and private, and especially from the groups that speak on behalf of children and their needs, such as the maternal and child health community.
Representative terms from entire chapter: