a larger issue: that adults as well as teenagers have difficulty planning and preventing pregnancy.

Another major force stimulating the Institute of Medicine's initial interest in studying unintended pregnancy was a concern that too little attention had been given to the relationship of pregnancy intendedness to the health and well-being of children. Throughout the late 1980s and early 1990s, there was an appreciable amount of advocacy on behalf of children. Even in the face of limited budgets and competing demands, many states and the federal government found numerous ways to direct money and attention to children: expanding eligibility for Medicaid in order to finance health care for more low-income children and pregnant women; increasing authorizations for the popular Head Start program; and stimulating programs in virtually every state to address infant mortality and early childhood immunization, improve the quality of education, offer early intervention services for at-risk families, reach pregnant women with prenatal care, and use school settings in new ways to provide a wide variety of human services.

But the world of education, counseling, and care that supports careful contraceptive use—often called family planning—has been starkly absent from the "children's agenda" as articulated over the past 10 to 15 years. In fact, pregnancy prevention and family planning have generally been treated as marginal or controversial activities, rarely discussed in a broad, comprehensive way that recognizes the important role that fertility control plays in the lives of men and women, in child and family well-being, and in the overall tenor of communities.2 In particular, pregnancy planning has not been included as a central, routine component of human services, especially preventive health care and education; by contrast, a number of other countries have found many ways to incorporate family planning services into primary care, often as part of maternal and child health services. As evidence of this neglect, public investment in family planning services declined during the 1980s, perhaps by as much as a third. In particular, federal outlays for family planning through the Title X program (that portion of the Public Health Service Act that provides grants to various state and local entities to offer family planning services to low-income women and adolescents) dropped precipitously during the 1980s, although increased commitments from other public and private sources helped to fill a portion of the gap (Ku, 1993; Gold and Daley, 1991).

An additional influence on this project was the intense debate about health care reform during the 103rd Congress and the growth of managed care systems

2  

Exceptions to this exclusion were the March of Dimes' report, Towards Improving the Outcome of Pregnancy (1993), and the Carnegie Corporation of New York's report, Starting Points (1994), both of which highlighted the key role that pregnancy planning can play in the health and lives of children, women, and families.



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