The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families

This report is about unintended pregnancy, a general term that includes pregnancies that a woman states were either mistimed or unwanted at the time of conception. Unintended pregnancy in the United States is an important and complex problem that has significant consequences for the health and well-being of all Americans.

The study that culminated in this report was shaped and influenced by a wide variety of both demographic and social phenomena. For example, data published in the 1980s indicated that rates of unintended pregnancy in the United States were higher than those in several other Western democracies. Data also revealed that although there had been a decline in births derived from unintended pregnancies in the 1970s and early 1980s, rates increased in the middle to late 1980s, with increases particularly marked among the poor, as evident in the 1988 National Survey of Family Growth. These figures indicated that progress on one of the most basic measures of women's autonomy--determining whether and when to bear children--had eroded, a development that could only undermine efforts to improve women's capacity for self-determination and full participation in their communities. Moreover, increases in the number of births derived from unintended pregnancies were not confined to adolescents, which suggested that the nation's continuing focus on teenage pregnancy might well be missing a larger issue: that adults too, not just teenagers, are having difficulty in preventing and planning pregnancy.

Many other factors also stimulated the Institute's interest in unintended pregnancy: a concern that too little attention has been given to the relationship of pregnancy "intendedness" to the health and well-being of children; the intense debate about health care reform during the 103rd Congress and the growth of managed care systems throughout the nation, both of which have revealed underlying disagreements about whether and how contraception should be financed and about the systems that should be in place to provide reproductive health services generally; and intensifying discussions about welfare reform and, in particular, whether welfare itself might provide an inappropriate incentive for childbearing. The HIV and AIDS epidemic was also an important part of this project's genesis. Data now suggest that the incidence of HIV infection among women is accelerating at an alarming rate. Moreover, the epidemic has apparently increased the willingness of the public and some elected officials to address more candidly such issues as high-risk sexual behavior and at least one form of contraception--condoms.

It is also important to acknowledge two additional issues that shaped this study: the controversies over abstinence-based sex education and over abortion. During the 1980s, there was a movement at the federal level, and among some communities as well, to promote abstinence instead of contraception as the major means of preventing pregnancies (as well as AIDS and sexually transmitted diseases [STDs]) among unmarried adolescents. This argument spawned impassioned debates about whether abstinence was an outmoded concept in the late twentieth century that ignored the realities of adolescent sexual activity, and about whether discussing contraception with teenagers gave tacit approval to their sexual activity, or perhaps even encouraged it. Disagreements were especially intense over whether school-based sex education for adolescents should stress abstinence only, or should combine messages about abstinence with material on contraception as well. Although some federal health officials took the former position, other people, especially those in the family planning field, took the latter view, thereby often finding themselves at odds with federal policy leaders. The intensity of the debate had the unfortunate effect of polarizing many groups who share a common interest in reducing adolescent pregnancy. Thus, the time seemed right for a review of the knowledge base regarding the causes, consequences, and prevention of unintended pregnancy, including the effectiveness of abstinence-based education.

Abortion is perhaps the most divisive issue related to unintended pregnancy. As any observer of the American scene over the last 20 years would note, the abortion controversy has dominated discussions of reproductive health and has led to painful divisions across many ideological, political, and religious lines. In particular, the heated debate over the acceptability of abortion itself has diverted attention from many other important and closely related issues, such as finding ways to encourage couples to prevent both unintended pregnancy and STDs simultaneously or learning how best to offer contraceptive services in communities whose health care systems are changing rapidly. Put another way, in arguing about how to resolve problem pregnancies, less attention has been given to preventing such pregnancies in the first place.

Within this broad context, the Institute of Medicine's Committee on Unintended Pregnancy was established to explore the relationship of unintended pregnancy in the United States to the health and well-being of children and families and to make recommendations for policy, practice, and research. In so doing, the committee was asked to:

• define what is meant by unintended pregnancy and related terms used in the relevant data and research;
• summarize evidence on the effects that unintended pregnancy (e.g., both mistimed and unwanted pregnancy) has on the health and well-being of children, youth, and adults (to include commentary on the role of abortion in resolving unintended pregnancies);
• analyze patterns of and trends in unintended pregnancy, including data on the populations in whom unintended pregnancy is concentrated;
• outline the various reasons that might help to explain the observed patterns;
• describe the range of programs that have been organized in the last 10 years or so to reduce the incidence of unintended pregnancy and, to the extent possible, comment on the effectiveness of various approaches; and
• make conclusions and recommendations for policy, practice, and research based on the data assembled and reviewed.

In meeting its charge, the committee and staff used several methods to gather needed information. It reviewed already published data and analyses; studied numerous commissioned and contributed papers on a variety of topics about which the group felt it needed more information; talked informally, during committee meetings and at other times, with experts on the various topics it was studying; requested one original piece of analytic work by the Alan Guttmacher Institute using the 1988 National Maternal and Infant Health Survey; conducted an analysis of what the childbearing population in the United States would look like if unintended pregnancies were eliminated; and held five meetings of the full committee over a 13-month period (from September 1993 through October 1994). In addition, a careful effort was made to learn about programs in place around the country that address unintended pregnancy in some way. Both committee members and staff participated in drafting the report.

This report represents the collaborative efforts of many groups and individuals, particularly the supervising committee and staff whose names appear at the beginning of this document. The topic addressed by this study proved to be an unusually complicated one, and it required great dedication and effort by all concerned to complete the report that appears here.

Particularly helpful were the many papers developed for the committee. These papers assisted the committee in understanding and integrating many disparate sets of information; in the full report, the papers and their authors are listed in Appendix A. Major portions of some papers were incorporated directly into the report itself. For example, material drafted by Kristin Moore and Dana Glei formed the backbone of Chapter 2; text drafted by Jim Marks and Kristin Moore and by committee members Larry Bumpass, George Little, Sara McLanahan and, in particular, Carol Hogue, were relied on heavily in Chapter 3; the work of committee member Allan Rosenfield and of Lisa Kaeser, Cory Richards, Jane Brown, and Jeanne Steele contributed to much of Chapter 5; a review article by Nancy Adler and Warren Miller assisted in the conceptualization of Chapter 6; and the work of committee members Lorraine Klerman and Marie McCormick and of Vanessa Gamble, Judith Houck, Mort Lebow, William D'Antonio, and Allan Carlson contributed substantially to Chapter 7. Rebecca Maynard and committee members Mark Montgomery and Lorraine Klerman also provided much helpful material for Chapter 8. Finally, it is important to acknowledge the particular contributions of committee members Carol Hogue, Larry Bumpass and Mark Montgomery who developed the important technical materials in Appendixes D, E, and G, respectively. All sections benefited enormously from the careful review of research on the determinants of contraceptive use developed by Koray Tanfer, as well as from the thoughtful paper on men and family planning by Freya Sonenstein and Joseph Pleck. To all of these scientists, the committee expresses its deep admiration and appreciation.

In addition, the committee extends special gratitude to a number of colleagues who provided much assistance along the way, especially Christine Bachrach, Wendy Baldwin, Marie Bass, Jerry Bennett, Doug Besharov, Virginia Cartoof, Jan Chapin, Henry David, Sara DePersio, Judith DeSarno, Joy Dryfoos, Erica Elvander, Shelly Gehshan, Rachel Gold, Debra Haffner, Carol Herman, Ruth Katz, Woodie Kessel, Doug Kirby, Rebecca Maynard, Arden Miller, Warren Miller, Kathy Morton, Sarah Samuels, Mike Stoto, James Trussell, and Laurie Zabin. Analysts with the National Center for Health Statistics were of enormous assistance as well--William Mosher, Kathryn London, Linda Peterson, and Linda Piccinino. Similarly, the leadership and staff of The Alan Guttmacher Institute were unfailingly helpful, especially Jeannie Rosoff and Jacqueline Forrest, as were their countless publications on many issues central to this report. Finally, Elena Nightingale and Lisbeth Schorr in particular offered much encouragement and assistance in the early stages of this study; their special contributions are gratefully acknowledged.

The Institute of Medicine staff that assured the completion of this document, Dana Hotra and Alison Smith, worked exceedingly hard on this project and have the deepest respect and appreciation of all concerned. Dana helped to draft much of Chapter 2 and completed virtually all of Chapters 4 and 8 and Appendix F. Alison drafted two key sections of Chapter 3 and also prepared the manuscript for publication. In doing so, she improved the appearance and accuracy of the final product immeasurably. Finally, the committee acknowledges the many contributions of editors Mike Edington, Michael Hayes, and Elaine McGarragh.

This report was funded by the combined efforts of three groups: the Carnegie Corporation of New York, The Robert Wood Johnson Foundation, and the U.S. Public Health Service (specifically, the Maternal and Child Health Bureau, the Centers for Disease Control and Prevention, the National Institute of Child Health and Human Development, and the Office of Population Affairs). Their willingness to finance a study on the causes, consequences, and prevention of unintended pregnancy took no small degree of commitment, inasmuch as this issue continues to be sensitive, even controversial, in some sectors. Their encouragement and funding are gratefully acknowledged.

Sarah S. Brown, Senior Study Director
Leon Eisenberg, Committee Chair

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