5
Basic Requirements: Contraceptive Knowledge and Access

The patterns of contraceptive use, misuse, and nonuse described in the previous chapter are troubling because a common result is unintended pregnancy. These patterns are also quite puzzling; with so many different contraceptive devices in existence, some widely available, even in drugstores, what is the explanation for inadequate contraceptive vigilance?

This chapter reviews two factors that might help to explain these observed patterns. The first is that inadequate use of contraception may be traceable in part to insufficient knowledge about methods of birth control and related issues of human reproduction, as well as to difficulty in mastering the skills that many reversible methods of contraception require. This section also considers the adequacy of school-based education and information about contraception.

The second issue considered is that access to contraceptive services and supplies—particularly for the more effective methods—may be limited. Later chapters discuss various personal and interpersonal factors that affect contraceptive use and therefore unintended pregnancy (Chapter 6), as well as the broader sociocultural and economic environments in which decisions about contraception and pregnancy are made (Chapter 7).

This focus on knowledge, skills, and access is not meant to obscure another possible explanation for unintended pregnancy, which is the relatively limited and often unsatisfactory array of contraceptive methods available to men and women in the United States. Experts in contraception and family planning, as well as men and women themselves, have long noted that the existing array of methods is often ill suited to the varying needs of couples and individuals over time, and that some methods are too difficult or unpleasant to use consistently,



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--> 5 Basic Requirements: Contraceptive Knowledge and Access The patterns of contraceptive use, misuse, and nonuse described in the previous chapter are troubling because a common result is unintended pregnancy. These patterns are also quite puzzling; with so many different contraceptive devices in existence, some widely available, even in drugstores, what is the explanation for inadequate contraceptive vigilance? This chapter reviews two factors that might help to explain these observed patterns. The first is that inadequate use of contraception may be traceable in part to insufficient knowledge about methods of birth control and related issues of human reproduction, as well as to difficulty in mastering the skills that many reversible methods of contraception require. This section also considers the adequacy of school-based education and information about contraception. The second issue considered is that access to contraceptive services and supplies—particularly for the more effective methods—may be limited. Later chapters discuss various personal and interpersonal factors that affect contraceptive use and therefore unintended pregnancy (Chapter 6), as well as the broader sociocultural and economic environments in which decisions about contraception and pregnancy are made (Chapter 7). This focus on knowledge, skills, and access is not meant to obscure another possible explanation for unintended pregnancy, which is the relatively limited and often unsatisfactory array of contraceptive methods available to men and women in the United States. Experts in contraception and family planning, as well as men and women themselves, have long noted that the existing array of methods is often ill suited to the varying needs of couples and individuals over time, and that some methods are too difficult or unpleasant to use consistently,

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--> while others are too expensive or unsatisfactory in some other way. This underlying discontent with current contraceptive technology is at the heart of repeated calls for expanded research to develop new forms of contraception (Chapter 9). It is also important to emphasize here that the committee considers knowledge about methods of birth control, as well as access to them, to be basic requirements for effective contraceptive use. This view is consistent with observations about such other preventive interventions as prenatal care and immunizations, where the point has been made that both knowledge and access are necessary preconditions to use (Institute of Medicine, 1994, 1988). However, as subsequent material suggests, these basic elements, on their own, may not be enough to produce careful and consistent use of contraception; they are necessary but may not always be sufficient to prevent unintended pregnancy. Put another way, it is unreasonable to expect widespread, careful use of contraception in the absence of basic knowledge and access to services, but this does not mean that when such pieces are in place good contraceptive use is guaranteed. This perspective is developed in more detail in Chapter 6. Knowledge, Skills, and School-Based Education One of the explanations most often given for unintended pregnancy is that men and women, especially those who are teenagers, are poorly informed about contraception and related topics in reproductive health. Accordingly, this section considers that explanation and also addresses the skills needed to use many reversible methods. The section concludes with a discussion of school-based education and information about contraception. Contraceptive Knowledge Individuals learn about contraceptive methods, including their risks and benefits, as well as how to use them, from a wide variety of sources: friends and family, the electronic and print media, health professionals and the educational materials that they distribute, such institutions as schools and colleges, and numerous community resources. Unfortunately, few data are available to assess carefully the content and quality of the information provided in each of these settings. There are data about school-based sex education programs, summarized later in this chapter, but little on the content and quality of information available through the adolescent grapevine, for example. Few studies have addressed the education that parents offer their children about contraception, although some studies suggest that parents often do not discuss contraception with their children and that, in any event, such communication may not exert much of an effect on

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--> the child's subsequent use of contraception (Tanfer, 1994). Moreover, the information about media content—especially television—pertains more to its overall sexual content than to its information about contraception (Chapter 7). There is, however, clear evidence that many Americans are misinformed about the risks and benefits of particular contraceptive methods—exaggerating the former and underestimating the latter, especially in the case of oral contraceptives. For example, a 1993 Gallup poll found that more than half of American women believe there are ''substantial risks" (mainly cancer) involved in using the birth control pill, and 4 in 10 erroneously believe that the health risks of taking oral contraceptives are greater than those of childbearing (Gallup Organization, 1994). The widespread lack of knowledge among both providers and potential users regarding emergency contraception1 is another indication that many Americans lack basic information about all available means of contraception (Grossman and Grossman, 1994; Trussell and Stewart, 1992). Numerous smaller studies confirm this general picture. Balassone (1989), for example, conducted a prospective study of 76 sexually active teenaged women securing oral contraceptives at several private family planning clinics, and found that, in general, the young women underestimated the chances of pregnancy in the absence of contraception, and had inaccurate knowledge regarding the effectiveness of various contraceptive methods. In 1991, 247 women (mean age of 30.2 years) receiving care at a university health center were queried about their views of the benefits and risks of the pill. Almost half believed that oral contraceptives carry substantial risks, cancer in particular. Large percentages—between 80 and 95 percent—were unaware of the health benefits of oral contraceptives other than pregnancy prevention (e.g., the protective effect against benign breast disease, the reduced risk of both ovarian and endometrial cancer, and the lowered risk of pelvic inflammatory disease) (Peipert and Gutmann, 1993). Similarly, Lowe and Radius (1987) reported that "dangerous misconceptions" prevailed among unmarried college students with regard to knowledge of anatomy, physiology, and the appropriate use of effective contraception. And in their study sample of low-income black adolescents, Poland and Beane (1980) reported that teenagers articulated the common mythology that IUDs, for example, can "get lost in the body," and that 1   Emergency contraception refers to using oral contraceptives or other hormones up to 72 hours after unprotected intercourse or inserting an intrauterine device (IUD) up to 7 days after unprotected intercourse. Emergency contraception via oral contraceptives reduces the risk of pregnancy by about 75 percent; emergency contraception accomplished via the post-coital insertion from an IUD is even more effective, approaching 100 percent. Though not recommended as a routine method of pregnancy prevention, emergency contraception can serve as an entry point for regular contraceptive care and use (Hatcher et al., 1995; Trussell and Stewart, 1992).

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--> if pregnancy occurs with an IUD in place, the baby will be born with the device in it somewhere. One reason that Americans are misinformed about contraception generally may be that the electronic media tend to report more of the bad news than the good news about various methods. Some data support this widely held view—especially the notion that the protective health benefits offered by various contraceptives are often underpublicized compared with the modest risks (Peipert and Gutmann, 1993; Adams Hillard, 1992). Clinic personnel report, for example, that adverse media coverage of Norplant has led to requests for removal of the implant, even among women who were experiencing no problems (Herman, 1994). Additional material is presented in Chapter 7 suggesting that although the electronic media present copious amounts of sexually enticing material, they rarely air complementary information on how to prevent such consequences of sexual activity as unintended pregnancy or sexually transmitted diseases (STDs). Numerous studies of adolescents have clearly shown that many also have very limited and often faulty information about when fertility begins, the timing of fertility within the menstrual cycle, and the probability of conception (see, for example, Clark et al., 1984; Cvetkovich and Grote, 1983; Oskamp and Mindick, 1983; Foreit and Foreit, 1981). A common reason given by adolescents for nonuse of contraception is that on a given occasion, the risk of pregnancy was judged to be low because of the "time of month." Yet research has confirmed that a substantial proportion of those who cite time of month as the reason for foregoing contraception could not correctly identify the period of greatest risk (Tanfer, 1994). It is not just adolescents who have incorrect information about human sexuality and contraception, however; adults may as well. When the Annie E. Casey Foundation began working in the early 1990s with groups of parents to improve their communication with young people about sex, contraception, and related topics to reduce teenage pregnancy (as part of the foundation's Plain Talk initiative), program leaders quickly learned that the parents themselves had major gaps in their knowledge about the topics at hand and that they needed help not only in communicating about sexual issues, but also in mastering basic information (S.L. Edwards, pers. com., 1994). Polling data on STDs also suggest a widespread lack of accurate information regarding sexual health. In 1993, the Campaign for Women's Health and the American Medical Women's Association sponsored a poll (via telephone interviews with 1,000 randomly selected women aged 18–60) to learn more about American women's knowledge about STDs generally. Key findings included the following: 84 percent said they are not worried about contracting an STD (including 78 percent of those with multiple partners); 66 percent knew virtually nothing about STDs other than HIV and AIDS; only 1 in 10 reported being "very knowledgeable" about STDs; only 11 percent knew that many STDs

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--> can be more harmful to women's health than to men's; and 53 percent viewed STDs as a "dirty" disease that represents either shame or punishment (Campaign for Women's Health and American Medical Women's Association, 1994). Such misinformation can lead to poor contraceptive use and therefore unintended pregnancy. A study in the mid-1980s, for example, probed reasons that sexually active teenage women delay making a first visit to a family planning clinic. Information was collected from more than 400 sexually active young women under age 19 attending family planning clinics and from about 400 sexually active female students at two junior and two senior high schools. Across all groups, one of the most commonly cited reasons for delay in attending a family planning clinic was that contraception is "dangerous." For example, among those who had never gone to a clinic at all, 19 percent cited this reason as the most important factor explaining their delay, and an additional 45 percent listed it as a "contributing" factor (Zabin et al., 1991). Similarly, in the Balassone (1989) study mentioned earlier, the subjects least likely to continue using oral contraceptives at 3 months' follow-up were those who believed that there were appreciable health-related problems associated with using oral contraceptives, felt that their risk of pregnancy was less than that of their peers, and had poor problem-solving skills. Chapter 6 presents more detailed information on the fears, attitudes, and feelings that can influence contraceptive use. In sum, there is significant misinformation among both adults and adolescents about the risks and benefits of contraception. This lack of knowledge can limit efforts to obtain contraception and continue using it, thereby increasing the risk of unintended pregnancy. Contraceptive Skills Knowledge about contraception is particularly important because many reversible methods of contraception require considerable skill for proper use. Patient package inserts, education and counseling sessions at many birth control clinics, and various popular books attempt to educate users about the nitty-gritty of how to use specific methods and how to manage problems that are commonly encountered. But practitioners in the field, such as workers in family planning clinics, report that there is great variation in the abilities of clients to use methods properly and that there may not be adequate appreciation of the difficulty faced in mastering the mechanics of contraception (Quint et al., 1994). To use a diaphragm correctly, for example, one must know at a minimum where to go to get the method, how to insert the device properly and to check its position, how much spermicide to apply, how many hours after intercourse to remove it, how to insert additional spermicide into the vagina if repeated intercourse will occur while the diaphragm is still in place, and how to check for

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--> holes or tears in the device. Moreover, this information must be used properly each time that the diaphragm is employed, and the user must be willing to forego intercourse or use alternative methods of contraception if the diaphragm is unavailable for some reason. An equally long list of complexities is attached to oral contraceptive use (Oakley, 1994), as noted in Chapter 4. Rarely do contraceptive counselors have the time to cover all of these issues or to reinforce key messages through follow-up, which is one of the reasons that the longer-acting methods (such as hormonal implants and injections) continue to attract interest. Reflecting these difficulties, Adams Hillard (1992) reports that adolescents miss taking an average of three pills monthly and between 20 and 30 percent of all users of oral contraceptives miss a pill every month. The complexity of the contraceptive task may also be one of the reasons that some studies have shown a link between education, cognitive functioning, and unintended pregnancy—specifically, that contraceptive use increases with education. With more years of schooling, a woman may be better equipped to understand the risks and benefits of becoming pregnant, to make plans to reduce that risk, and then to execute those plans. Consistent with this view, in a national sample of never-married women in their 20s at risk of pregnancy, when the effects of other social and demographic variables were controlled, education was found to be associated not only with better contraceptive use but also with the choice of more effective methods (Tanfer et al., 1992). Among urban female adolescents attending family planning clinics, the stage of cognitive development was found to be the best predictor of contraceptive decision-making (Sachs, 1985). Several studies have also shown that better educated or high-income women who use less effective methods use them more effectively than less educated or low-income women who use the same methods (Jones and Forrest, 1992, 1989; Grady et al., 1986, 1983; Schirm et al., 1982). School-Based Education and Information One source of contraceptive information and education that has been studied more thoroughly than others is schools. Most school-based sex education programs can be categorized into one of four types: (1) those that try to increase knowledge about reproductive health and especially about all methods of pregnancy prevention including abstinence, and emphasize the risk and consequences of pregnancy; (2) those that do the same and add material on "values clarification" and skills in communicating and decision-making; (3) those that advocate abstinence but do not discuss contraception; and (4) those that accompany comprehensive education in reproductive health with clinical services including family planning care. In both this section of the report and elsewhere (Chapter 8 especially), various aspects of these approaches are discussed.

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--> Public opinion and public policy both support a strong role for schools in educating young people about human sexuality, whatever the controversies in some communities. The American College of Obstetricians and Gynecologists, for example, commissioned the Gallup Organization to conduct a study of public knowledge of and attitudes toward contraception. This 1985 study of 1,036 women and 520 men aged 18 and over showed that approximately 90 percent of the adult population wanted sex education to be taught in schools. Fifty-four percent of women and 47 percent of men wanted it to start in elementary school; 81 percent of women and 74 percent of men wanted sex education to start before high school (American College of Obstetricians and Gynecologists, 1985). Similarly, the Sexuality Information and Education Council of the United States reports that there is strong public support for sexuality education, including explicit instruction about contraception and STD prevention. More than 8 in 10 adults support teaching about sexuality in the public schools; more than 9 in 10 want AIDS education for their children. Seventy-seven percent think that courses for 12-year-olds should include information about birth control. Almost two-thirds say that courses should include information about abortion, sexual intercourse, and premarital sex (Debra and DeMauro, 1990). Parents of students show their support for sexuality education in other ways. When given the option of excusing their children from sexuality education classes, less than 5 percent do so (Haffner, 1994). Mirroring public opinion, 47 states either recommend or mandate sexuality education; every state recommends or mandates AIDS education; and 38 states plus the District of Columbia and Puerto Rico have developed either state curricula or guidelines to shape the implementation of programs at the local level. Almost all state curriculum guides include abstinence messages as well as positive and affirming statements about human sexuality; topics most commonly covered are body image, reproductive anatomy, puberty, decision-making skills, families, abstinence, STDs, HIV and AIDS, sexual abuse, and gender roles (Haffner, 1994). Despite the public support and state policies, available school-based information and education about human sexuality in general and contraception in particular are insufficient in a number of ways. First, while it is true that many states require schools to provide sexuality education and HIV/AIDS education to students at different grade levels, it is also the case that in many states, the content of those educational programs is limited by statute or by state policy or both (The Alan Guttmacher Institute, 1989). The precise nature of these restrictions can serve to limit the effectiveness of the educational programs by, for example, prohibiting explicit discussion of topics directly related to pregnancy prevention, such as contraception. Second, a recent survey of state sexuality education curricula and guidelines revealed important gaps. The survey found that although contraception is included in a majority of the state guides, the coverage is often incomplete. Only

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--> 10 states have unambiguous messages about contraception at the junior high school level, and Iowa alone clearly includes introductory material at the elementary grade level. Only three states include coverage of contraception at both the junior and senior high levels, and condoms are mentioned in just five state curriculum guides. States vary as to which details they discuss concerning contraception, from simply identifying the concept to explaining the range of contraceptive techniques and relative effectiveness. Discussing contraceptive use with a partner is rarely covered. A 1992 study of HIV and AIDS education programs nationwide found a similar lack of prevention information; only five states adequately discussed condom use (Haffner, 1994). Moreover, it is apparent that many of the available instructional materials, particularly those provided by state agencies, are inadequate, as is the training provided to teachers of sexuality education (The Alan Guttmacher Institute, 1989). For example, a 1987 survey of secondary school sex education teachers found clear evidence of misinformation about various methods of contraception; 77 percent held the erroneous belief that women taking oral contraceptives should stop from time to time to "give the body a rest" (Forrest and Silverman, 1989). A different, slightly dated analysis, the National Longitudinal Survey of Youth (NLSY)—a survey of a nationally representative sample of more than 12,000 young people aged 14–22 in 1979, who were reinterviewed in 1984 at ages 19–27—paints an equally checkered picture. Marsiglio and Mott (1986) found that by age 19, a bare majority (60 percent of the men and 52 percent of the women) reported that they had taken a sex education course in school, although the probability of having taken a sex education course in early adolescence was seen to increase over time. Even those who had taken a course, however, revealed important gaps in knowledge about such basic issues as when in a woman's menstrual cycle she is relatively more and less fertile. One of the most important and sobering findings of the NLSY is that many teenagers become sexually active before having taken a sex education class. The investigators concluded: "Among young people who waited until age 18 to start having sex, 61 percent of women and 52 percent of men had already been exposed to a sex education course …; but among those who started at 16 or younger, fewer than half—in the case of males, considerably fewer—had taken a course. Furthermore, only 35 percent of young people who became sexually active at age 18 had previously received course instruction about where to obtain contraceptives, and only about 57 percent of the more limited group of course takers had received such instruction" (Marsiglio and Mott, 1986:160). The issue of the effects of such instruction on the sexual and reproductive behavior of young people has been passionately debated, with opponents claiming that it actually increases the level of sexual activity which in turn leads to nonmarital pregnancy and other problems, and proponents denying any such effect and claiming that it probably reduces the rate of pregnancy by promoting

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--> more effective contraceptive practice. It is difficult for research to resolve this debate definitively because of the wide variation in the content and depth of the sex education offered, differences in the research definitions of "sex education," the reluctance of schools and agencies to allow evaluation of the effects of such courses, and deficiencies in some study designs (Furstenberg et al., 1985; Kirby, 1984; Scales, 1981; Spanier, 1976). There are, however, several bodies of information that shed light on this topic. National survey data present mixed results, but indicate that adolescents who receive sex education are more likely to use contraception than those who do not receive such instruction (Ku et al., 1993, 1992; Dawson, 1986; Marsiglio and Mott, 1986; Furstenberg et al., 1985; Zelnik and Kim, 1982). Retrospective surveys, however, cannot provide causal associations; such associations can only be made through evaluations with experimental or quasi-experimental designs. Unfortunately, few evaluations are so methodologically rigorous, and most fail to measure behavior change and long-term program effects (Chapter 8). In an attempt to address the lack of rigorous assessment, Kirby (1984) used quasi-experimental designs to evaluate 15 well-regarded sex education curricula from the 1970s and early 1980s. He concluded that the programs did increase knowledge about various topics in reproductive health, but did not change sexual behavior or contraceptive use. This discouraging picture appears to be changing. In a 1994 review, Kirby and colleagues suggest that both programs and evaluation methods have improved. Evidence from more than 20 surveys and studies of school-based sex and HIV and AIDS education programs indicates that specific programs delayed the initiation of intercourse, reduced the frequency of intercourse, reduced the number of sexual partners, or increased the use of contraceptives. In addition, available data indicate clearly that participation in these sexuality education programs has not been found to encourage adolescents to initiate sexual intercourse, or to increase the frequency of intercourse among adolescents who were sexually active before the program. The sex education programs reviewed by Kirby and colleagues (1994) clustered into three types: (1) abstinence-only programs that do not discuss contraception, (2) sexuality or AIDS education programs that discuss both abstinence and contraception, and (3) programs that provide comprehensive reproductive health education covering many topics including contraception and abstinence, as well as clinical services. Abstinence-only programs appear to affect attitudes regarding premarital intercourse, but the few evaluations that measure behavior change are limited by methodological problems, and there is insufficient evidence to determine whether abstinence programs delay the age of first intercourse or affect other sexual and contraceptive behaviors. Effects of programs of the second type are mixed, but those that most successfully delay sexual intercourse or increase contraceptive use appear to focus on the "particular facts, values, norms, and skills necessary to avoid sex or unprotected

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--> sex" (Kirby et al., 1994:355). The impact of school-based or school-linked reproductive health services is inconclusive, but the largest behavioral effects are observed in sites with strong educational components. Although these programs may not represent the average school-based sex education curriculum in current use (see, for example, Firestone, 1994), many communities are attempting to replicate the more effective models in new sites. In Chapter 8, several of these carefully evaluated programs are discussed in more detail. A final point needs to be made. Whatever the merits of the various school-based programs being developed around the country, there are virtually no parallel programs for older men and women. Perhaps there is an unstated national belief that adults already know enough about reproduction, contraception, and related topics, or that what they do not know they can find out. Perhaps the absence of an institutional base, like the school system, for offering education about reproductive health to adults explains the gap. Whatever the reason, inadequate contraceptive use is seen in all age groups, not just adolescents, and therefore adults too may benefit from better information and education in this area. Access to Contraception To what extent is inconsistent or nonuse of contraception, and therefore unintended pregnancy, due to a lack of access to birth control services and supplies? In particular, to what extent is there limited access to the more effective methods of birth control, leading couples to rely on less effective methods which, by definition, have higher failure rates? Unfortunately, answering these questions is difficult because access varies by the method being considered (condoms versus hormonal implants, for example), and because contraception can be secured through a variety of sources and systems—from pharmacies and condom boutiques to clinics, hospital centers, and private physician offices. Nonetheless, this topic attracts strong opinions on both sides. On the one hand, some have argued that, with condoms and spermicides available in virtually every drugstore, allegations of limited access to contraception are clearly fatuous. On the other hand, public health analysts point with alarm to the decline in constant dollar support for the Title X program (the family planning grant program authorized under the Public Health Service Act that targets reproductive health services to low-income women and adolescents) (Ku, 1993; Gold and Daley, 1991), and to the major financial barriers to care that women may experience, both those with private health insurance and those without, when they try to obtain the more effective methods of contraception (Kaeser and Richards, 1994). There is widespread agreement, however, that whatever access problems exist, they pertain more to methods requiring a medical visit, such as oral

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--> contraceptives, than to nonprescription methods such as condoms or spermicides, which can be secured from many different types of facilities. Condoms in particular are increasingly available through a particularly wide variety of sources, including vending machines, largely in response to concern over the spread of various STDs including AIDS. Unfortunately, these nonprescription methods have significant failure rates and therefore appreciable rates of unintended pregnancy are associated with them. Nonetheless, they do provide more protection against unintended pregnancy than no method at all, and as such are an important part of pregnancy prevention. In this context, it is important to note that the number of nonprescription contraceptive devices—never very large—has recently been depleted by the removal of the contraceptive sponge from the market, leaving condoms and spermicides as the only nonprescription methods now available. The importance of inquiring carefully into contraceptive access is suggested by international comparisons of contraceptive use and various markers of unintended pregnancy and abortion. For example, a cross-national study completed by The Alan Guttmacher Institute considered the factors that might help to explain the higher rates of adolescent pregnancy, abortion, and childbearing in the United States as compared with those in various other industrialized countries (Chapter 2). One of the main conclusions of that analysis was that in those countries reporting more favorable rates, contraceptive services were apparently widely available, confidential, and very inexpensive, if not free (Jones et al., 1986). An additional analysis that examined adults as well as adolescents elaborated on this observation. The investigators concluded that contraceptive use—and, in particular, use of the more effective methods—was favorably affected by such factors as the presence of a national health plan or health care system that includes family planning services and that covers all citizens; the full integration of family planning services into general health care services, rather than such services being separate or specialist-based; the fact that family planning clinics are seen as serving all women, not just those who are poor or adolescent; the availability of free or subsidized supplies (oral contraceptives in particular); and supportive attitudes among providers (especially relevant to the prevalence of sterilization) (Jones et al., 1989). The importance of ease of access to contraceptive care also emerged from a comparison of U.S. and Danish family planning policies and practices. David and colleagues (1990) report that all people born or living in Denmark are entitled to free contraceptive counseling from a variety of sources, including the network of general practitioners who encourage the use of the more effective methods of contraception and make them readily available. Other cross-national comparisons are consistent with these perspectives (Klaus, 1993). Miller (1993, 1988), for example, suggests that the more favorable rates reported by numerous Western European and other industrialized countries on such maternal and child health measures as infant mortality reflect,

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--> clinic. The two most common reasons for the inability to make an appointment were no one answering the phone at all (five or more attempts were made) and being told that a doctor's referral was necessary before an appointment could be booked. Other reasons included requirements that a woman register at a clinic in person before an appointment for family planning could be made, and the absence of a doctor to offer care. Even those who were successful in making appointments frequently were put on hold repeatedly, sometimes for over 30 minutes. For those able to make an appointment, the mean number of days between the call and the appointment for all types of facilities was 20 working days, with the range in means across facilities being 10-51 working days. When the callers mentioned that they ''had no insurance," 4 in 10 were asked to bring cash to cover the full anticipated charges, which averaged $79.00. The authors concluded that because the family planning system was so underfunded and poorly organized, access was very limited and that therefore, as noted earlier, succeeding in the task of making a family planning appointment in the New York City system requires "motivation, persistence, and fortitude" (Mayor's Advisory Council on Child Health, 1993). Female sterilization offers another example of multiple entanglements. Despite the heavy reliance by American women on sterilization (Chapter 4), data suggest that bureaucratic and institutional barriers may limit access to this procedure. For example, federal regulations for subsidized sterilization mandate a strict set of policies with which a provider must comply, including sterilization counseling, a signed consent form, a required 30-day delay between signing the consent form and performing the sterilization, and performing the procedure not less than 30 but no more than 180 days of the consent being signed. The intent of these policies is to protect women by ensuring informed and timely consent, and with good reason, given the past history of abuses (Chapter 7). But it is also true that the protective policies can sometimes create administrative burdens for hospitals and clinics that may limit the number of facilities offering this procedure—an outcome that may have the effect of placing additional burdens on low-income and minority women, the very women the policies were intended to protect. Physicians themselves may place additional requirements on women, thus hindering access to sterilization. Klerman and colleagues (1993) note that to minimize legal liability, operative risks, or risk of patient regret, physicians may require patients to lose weight prior to surgery, stop smoking, obtain a more extensive laboratory workup, be happily married, have a certain number of children, or be a certain age. Many low-income men also may find it difficult to obtain a sterilization. For example, less then 20 percent of publicly supported family planning clinics report providing male sterilization services (Burt et al., 1994). Hospitals that accept federal reimbursement for sterilization procedures often have long waiting lists for female sterilization because of the unavailability of physicians or operating rooms, the loss of patient records and consent forms,

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--> delayed laboratory tests, payment issues related to Medicaid eligibility, and the requirement in some states that the federal consent form be placed in the record preoperatively (Klerman et al., 1993). These problems can delay the procedure beyond the 60-day postpartum period so that a woman is no longer eligible for postpartum Medicaid coverage, or in some extreme cases, the procedure may be delayed past 180 days, resulting in a woman needing to start the administrative and consent procedure all over again. The 30-day waiting period can also be particularly burdensome. For example, if a woman signs a consent form while she is pregnant, asking to be sterilized at the time of delivery, a full 30 days must pass before the request can be honored. If by chance she delivers before the 30 days are up, the sterilization cannot be performed at the time of delivery, thereby requiring that she return to the hospital at some later time to be sterilized. Not surprisingly, one of the effects of all of these complexities is an increased risk of unintended pregnancy among women whose requests for sterilization cannot be accommodated immediately postpartum (Davidson et al., 1990). Missed Opportunities Thus far, this chapter has considered two broad explanations for inadequate contraceptive use: limited knowledge about and insufficient access to contraceptive services and supplies. This section considers another factor that may give some clues about how to increase both contraceptive knowledge and access. The tendency in the United States to offer health and human services in categorical, problem-specific ways may result in missing many opportunities to offer information, education, and services that help couples avoid unintended pregnancies. In a recent editorial advocating increased attention to immunizing children, U.S. Department of Health and Human Services Secretary Donna Shalala stated, "Every encounter of any sort that a physician or provider has with a patient—whether in an office or an emergency department or a hospital room—offers an opportunity to screen children for needed vaccines and administer appropriate vaccines immediately." Such screening "should become as routine as measuring blood pressure in adults" (The Blue Sheet, 1993:9). This perspective has not yet been articulated for contraceptive services, even though, just as for immunizations, many opportunities are present to improve the contraceptive vigilance of adults as well as adolescents. One example is the disinclination of many clinics that screen for and treat STDs to provide contraceptive services. Two recent investigations reveal clearly that the clients typically seen in STD clinics are often poor users of contraception, frequently have multiple sexual partners, lack much basic information about pregnancy and reproduction, and would be receptive to more information and to additional services to address their contraceptive needs. Upchurch and

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--> colleagues (1987) surveyed 516 women attending an STD clinic in an urban, inner-city area to learn about various contraceptive and sexual practices and knowledge. They documented high rates of STDs and STD recurrences and poor use of contraception. They concluded that making contraceptive services available in STD clinics could be of great help to the women typically seen in these clinics who are at high risk of unintended pregnancy and who are known to be poor users of contraception. Similar conclusions were reached in a more recent survey at another STD clinic (Horn et al., 1990). The categorical, single-problem focus also means that few drug treatment programs for men or women—even for women who are new mothers—emphasize contraception or preventing unintended pregnancies (Gehshan, 1994). For example, since 1988, the federal Center for Substance Abuse and Prevention (CSAP), in conjunction with the Maternal and Child Health Bureau, has funded more than 100 programs targeted to women of childbearing age, especially those who are pregnant or have a child less than 1 year old at the time of enrollment. Although the goals of the program grants could include an emphasis on preventing unintended pregnancy, a recent review of 112 projects receiving CSAP support in 1991 revealed that none had program objectives that included pregnancy prevention, nor did any of the program evaluations focus on this issue (Cartoof, 1994). Although there are many reasons for this state of affairs—not the least being that many drug treatment personnel are not trained in this area and have few extra resources to devote to this topic—several pilot projects have demonstrated that integration of drug treatment and family planning services is not only possible but also leads to better use of contraception (Armstrong et al., 1991). The practice patterns of pediatricians raise a similar point. Pediatricians' emphasis on preventive care makes them likely candidates to encourage the use of contraception. They are in a unique position to provide information both for their adolescent patients, many of whom have or will soon become sexually active, and for new parents as well in the form of interconceptional care. The subspecialty of adolescent medicine draws attention to the need for training in the health needs of teenagers, including those related to sexuality, but general pediatricians are only beginning to consider whether their work in protecting the health of infants and young children includes counseling mothers and couples about the need for reasonable intervals between births and the importance of being in good health before conception. The American Academy of Pediatrics reports that only 34 percent of surveyed physicians routinely ask their patients, when appropriate, about family planning (Clark, 1993). Klerman and Reynolds (1994) assert that all pediatricians should be educated to ask mothers about their plans for future pregnancies, and should be prepared to give advice about spacing of pregnancies and about contraceptive methods. They speculate that although some physicians may feel they are prying or overstepping their boundaries in discussing these matters, the issue seems very appropriate when

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--> it is raised in the context of the physical and emotional health of the infant being examined. For example, extending the interval between pregnancies can help to increase the amount of attention devoted to the present child or children and to improve the health of future children by allowing sufficient time for maternal recovery between pregnancies. The importance of an adequate interpregnancy interval for reducing the risk of low birthweight in subsequent pregnancies has recently been well documented, lending added importance to pregnancy spacing and interconceptional care (Rawlings et al., 1995). This is not to suggest that pediatricians be equipped and prepared to carry out a full examination in preparation for providing prescription-based methods of contraception, but rather that the physician raise the subject, and when appropriate, provide counseling, encouragement, and, at a minimum, a nonprescription contraceptive method or a referral. At the same time, it is important to acknowledge that because relatively few poor or minority children see a pediatrician regularly, only part of the childbearing population would be reached by this strategy. This notion of missed opportunities is not limited to the health sector. Many others in the helping professions are in a position to raise issues of pregnancy planning and contraception but fail to do so (Tyrer, 1994). The limited commitment of many school systems to education regarding contraception, human reproduction, and related issues has already been mentioned, and in Chapter 7, the potential role of the media in this area is also explored. Other sectors that could become involved include social service agencies, church-affiliated centers, homeless shelters, job training and employment services, and various community and neighborhood centers that provide integrated services to families. Intervention programs working with troubled families offer unique and important opportunities to engage parents in topics of pregnancy spacing and planning; for a wide variety of reasons, however, such opportunities are often passed over. Some case workers feel the subject of family planning is taboo or too controversial; sometimes the case workers sense that the underlying problems of families are so compelling that attempts to discuss family planning will be essentially futile; some perhaps fail to appreciate that improving the life prospects of the child currently in treatment will be compromised if another baby arrives too soon. Whatever the reluctance, there is a newly articulated view in the field of family-centered care, especially that provided to families with infants and toddlers, that contraception and pregnancy planning are important topics to address (Lieberman, 1993). A somewhat philosophical explanation for these missed opportunities to offer contraceptive information and services is that in the United States and many other countries as well, there may be a tendency to "overmedicalize" family planning—that is, to make contraception (especially the more effective methods) so definitively a medical service that access is, in fact, constrained, inasmuch as access to medical care generally can be difficult (Shelton et al., 1992). This view lies behind the current interest in providing oral contraceptives as over-the-counter

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--> rather than prescription drugs; the notion is that easing access to oral contraceptives would increase their use (Samuels et al., 1994). Similarly, some agencies are experimenting with providing the first several cycles of oral contraceptives to adolescents without requiring a pelvic examination at the outset, given that one of the reasons some adolescents are reluctant to begin using highly effective means of contraception is fear of pelvic examinations and medical procedures in general (Zabin and Clark, 1981; see also Beckman et al., 1992, and Chapter 6). Conclusion The data and perspectives presented in this chapter suggest that one of the reasons contraceptive use is inadequate—and that unintended pregnancy therefore continues to occur—is that Americans have important gaps in their knowledge about contraception in general, and about the risks and benefits of various methods of birth control in particular. The resulting fears and misconceptions can impede the use (including the continuation) of contraception, which in turn contributes to the risk of unintended pregnancy. The complexity of using some contraceptive methods properly may help to explain the observation that education and cognitive ability are positively associated with greater success in contraceptive use. Data suggest that high quality instruction in schools (only one of many information sources) about various aspects of human sexuality, including contraception, is not uniformly available nationwide; moreover, what is available may sometimes be too little and too late, inasmuch as a significant portion of young people begin sexual activity before having had the benefit of any formal education about contraception and related topics. Knowledge is increasing about how to structure school-based curricula to reduce both precocious sexual activity as well as to improve contraceptive use once sexual activity has begun. Nonetheless, all such information centers on adolescents, and little is known about how to improve the knowledge and skills of adults regarding contraception. It is also apparent that, through a combination of financial and structural factors, the U.S. health care system makes access to contraception a complicated, sometimes expensive proposition. Condoms, the most accessible form of contraception, provide valuable protection against STDs but must be accompanied by prescription-based methods to afford maximum protection against unintended pregnancy. Unfortunately, other accessible nonprescription methods (such as foam) neither prevent the transmission of STDs nor offer the best protection against unintended pregnancy. In particular, private health insurance participates poorly in the financing of contraception; eligibility and other restrictions on Medicaid support for contraception make it a source of steady

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--> financing only for the poorest women; and the net decline in public investment in family planning services, in the face of higher costs and sicker patients, may have led to a net decline in access to care for women who rely on publicly subsidized contraceptive services. Finally, too few providers of health care and social services use all available opportunities to discuss contraception and the importance of intended pregnancy to the health and well-being of women and men, children, and families. Within the health care community, this may be due to limited training in contraception as well as to such other factors as personal feelings about birth control and concerns about liability. Outside of the health care community, the lack of attention may be due to a sense that contraception is a medical issue, perhaps a touchy subject, or "not part of my job." The net effect of these missed opportunities is that only a limited range of providers and institutions are involved in helping Americans to know about—and acquire the means to prevent—unintended pregnancy. References Accreditation Council for Graduate Medical Education. Press Release. February 15, 1995. Adams Hillard PJ. Oral contraception compliance: The extent of the problem. Adv Contracept. 1992;8:13–19. The Alan Guttmacher Institute. Uneven and Unequal: Insurance Coverage and Reproductive Health Services. New York, NY; 1994. The Alan Guttmacher Institute. Risk and Responsibility: Teaching Sex Education in America's Schools Today. New York, NY: The Alan Guttmacher Institute; 1989. American College of Obstetricians and Gynecologists. News Release. Gallup Poll Shows What Public Knows and Thinks About Birth Control. Washington, DC; March 6, 1985. American Medical Association. Graduate Medical Education Directory, 1994–1995. Chicago, IL: American Health Information Management Association; 1994:91. Armstrong KA, Kenen R, Samost L. Barriers to family planning services among patients in drug treatment programs. Fam Plann Perspect. 1991;23:264–271. Balassone ML. Risk of contraceptive discontinuation among adolescents. J Adol Health Care. 1989;10:527–533. Beckman L, Harvey S, Murray J. Perceived contraceptive attributes of current and former users of the vaginal sponge. J Sex Res. 1992;29:31–42. The Blue Sheet. Childhood immunization hearing will be convened jointly by Senate and House committees April 21. F-D-C Reports; April 21, 1993;8–9. Burt MB, Aaron LY, Schack LR. Family planning clinics: Current status and recent changes in services, clients, staffing, and income sources . In Publicly Supported Family Planning in the United States. Washington, DC: The Urban Institute and Child Trends, Inc.; 1994.

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