The Best Intentions

Unintended Pregnancy and the Well-Being of Children and Families

Committee on Unintended Pregnancy

Division of Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE

Sarah S. Brown and Leon Eisenberg, Editors

NATIONAL ACADEMY PRESS
Washington, D.C.
1995



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--> The Best Intentions Unintended Pregnancy and the Well-Being of Children and Families Committee on Unintended Pregnancy Division of Health Promotion and Disease Prevention INSTITUTE OF MEDICINE Sarah S. Brown and Leon Eisenberg, Editors NATIONAL ACADEMY PRESS Washington, D.C. 1995

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--> Institute of Medicine • 2101 Constitution Avenue, NW • Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This project was funded by the Carnegie Corporation of New York, which does not take responsibility for any statements or views expressed; 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). Library of Congress Cataloging-in-Publication Data The best intentions: unintended pregnancy and the well-being of children and families / Committee on Unintended Pregnancy, Institute of Medicine, National Academy of Sciences; Sarah S. Brown and Leon Eisenberg, editors. p. cm. Includes bibliographical references and index. ISBN 0-309-05230-0 1. Pregnancy, Unwanted—Government policy—United States. 2. Birth control—Government policy—United States. 3. Birth control clinics—Utilization—United States. I. Brown, Sarah S. II. Eisenberg, Leon, 1922- · III. Institute of Medicine (U.S.). Committee on Unitended Pregnancy. HQ766.5.U5B47 1995 304.6'66'0973—dc20 95-12064 CIP Copyright 1995 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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--> Committee On Unintended Pregnancy Leon Eisenberg,* Chair, Maude and Lillian Presley Professor of Social Medicine and Professor of Psychiatry Emeritus, Department of Social Medicine, Harvard Medical School, Boston, Massachusetts Larry Bumpass, N.B. Ryder Professor of Sociology, Center for Demography and Ecology, University of Wisconsin at Madison (liaison from the Board on Children and Families, jointly sponsored by the Commission on Behavioral and Social Sciences and Education and the Institute of Medicine) Sharon Lovick Edwards, President, The Cornerstone Consulting Group, Inc., Houston, Texas Carol J.R. Hogue, Professor of Epidemiology and Jules and Deen Terry Professor of Maternal and Child Health, Rollins School of Public Health of Emory University, Atlanta, Georgia Sylvia Drew Ivie, Executive Director, T.H.E. Clinic, Los Angeles, California Robert L. Johnson, Professor of Clinical Pediatrics and Psychiatry, Director of Adolescent and Young Adult Medicine, New Jersey Medical School, Newark Lorraine V. Klerman, Chair, Department of Maternal and Child Health, School of Public Health, University of Alabama at Birmingham George A. Little, Professor of Pediatrics and Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire Marie C. McCormick, Chair, Department of Maternal and Child Health, Harvard School of Public Health, Boston, Massachusetts (liaison from the Institute of Medicine Board on Health Promotion and Disease Prevention) Sara S. McLanahan, Professor of Sociology and Public Affairs, Office of Population Research, Princeton University, Princeton, New Jersey Mark R. Montgomery, Associate Professor, Department of Economics, State University of New York at Stony Brook, Stony Brook, New York Helen Rodriguez-Trias, Pediatrician-Consultant in Health Programming, Brookdale, California Allan Rosenfield,* Dean, School of Public Health, Columbia University, New York, New York *   IOM Member

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--> Study Staff Sarah S. Brown, Senior Study Director Dana Hotra, Research Associate Alison E. Smith, Research Assistant Michael A. Stoto, Director, Division of Health Promotion and Disease Prevention

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--> Acknowledgments This report on unintended pregnancy 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; a full listing of them is in Appendix A. These papers assisted the committee in understanding and integrating many disparate sets of information. In addition, 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; sections 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 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

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--> 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 and others listed in Appendix A, the committee expresses its deep admiration and appreciation. In addition, we extend 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, 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 (AGI) were unfailingly helpful, especially Jeannie Rosoff and Jacqueline Forrest, as were AGI's 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 who 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, we acknowledge the many contributions of our 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 BROWN, SENIOR STUDY DIRECTOR LEON EISENBERG, COMMITTEE CHAIR WASHINGTON, 1995

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--> Contents     Summary   1 1   Introduction   11     Focus of this Report   17     Study Methods and Report Organization   17 2   Demography of Unintended Pregnancy   21     Terminology   21     Percentage Rates of Unintended Pregnancy   25     Women at Risk of Unintended Pregnancy   28     Women Who Have Unintended Pregnancies   31     Trends in Unintended Pregnancy   33     The Role of Abortion   41     International Comparisons   42     Conclusion   47 3   Consequences of Unintended Pregnancy   50     Abortion as a Consequence of Unintended Pregnancy   51     Maternal Demographic Status   55     The Effects of Intendedness   63     Preconception Care   76     The Demographic Implications of Reducing Unintended Pregnancy   79     Conclusion   80

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--> 4   Patterns of Contraceptive Use   91     Patterns of Contraceptive Use and Unintended Pregnancy   92     Contraceptive Use Among Men   111     Use of Dual Contraceptive Methods   118     Sexually Transmitted Diseases   119     Conclusion   122 5   Basic Requirements: Contraceptive Knowledge and Access   126     Knowledge, Skills, and School-Based Education   127     Access to Contraception   135     Missed Opportunities   150     Conclusion   153 6   Personal and Interpersonal Determinants of Contraceptive Use   160     A Comment on Available Data   161     Underlying Themes   161     Single Factor Investigations   166     Conclusion   176 7   Socioeconomic and Cultural Influences on Contraceptive Use   183     Diversity in U.S. Culture   184     Conflicting Views About Sexuality   188     Economic Influences on Fertility   194     Racism   198     Violence   203     Gender Bias   205     Opposition to Abortion   208     Conclusion   211 8   Programs to Reduce Unintended Pregnancy   218     National Programs   218     Local Programs   223     Cross-Cutting Themes   231     The Fiscal Impact of Family Planning Funding   240     Conclusion   244 9   Conclusions and Recommendations   250     A New Social Norm   251     The Campaign to Reduce Unintended Pregnancy   253     Campaign Leadership   270

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-->     Appendixes      A Commissioned and Contributed Papers   275     B The Political Storms over Family Planning: Supplement to Chapters 1 and 7   278     C The National Survey of Family Growth: Principal Source of Statistics on Unintended Pregnancy: Supplement to Chapter 2   286     D Tables of Odds Ratios: Supplement to Chapter 3   296     E Technical Notes on the Recalculation Exercise: Supplement to Chapter 3   308     F Summaries of Evaluated Programs: Supplement to Chapter 8   311     G Assessing Program Effectiveness and Cost-Effectiveness Supplement to Chapter 8   338     Index   367

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The Best Intentions

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