2
Demography of Unintended Pregnancy

A majority of all pregnancies in the United States are unintended. About half of these unintended pregnancies result in live births and the other half are resolved by abortion. This chapter explores these two facts in detail after first defining unintended, mistimed , and unwanted pregnancies and commenting on the available data. Overall trends in births derived from unintended pregnancies are presented, along with the characteristics of women who experience such pregnancies and births. The chapter's penultimate section discusses the position of the United States in relationship to other developed countries on these measures.

Terminology

Women often informally discuss their personal feelings about the timing of the pregnancies they have had—whether a baby came just a bit too early, whether a pregnancy occurred at a time when it interfered with future plans but would have been wanted at a later time, whether a baby had been desperately sought for several years and was the answer to heartfelt prayers, or whether a pregnancy was not wanted at any time. Some women feel ambivalent or may disagree with their partners, one wanting a pregnancy and the other preferring to wait. Books, movies, dormitory discussions, real-life arguments, pillow talk, and conversations over the back fence focus on the complexities of wanted, unwanted, and mistimed pregnancies. It is difficult, however, to quantify people's feelings and sort them into categories that hold comparable meaning



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--> 2 Demography of Unintended Pregnancy A majority of all pregnancies in the United States are unintended. About half of these unintended pregnancies result in live births and the other half are resolved by abortion. This chapter explores these two facts in detail after first defining unintended, mistimed , and unwanted pregnancies and commenting on the available data. Overall trends in births derived from unintended pregnancies are presented, along with the characteristics of women who experience such pregnancies and births. The chapter's penultimate section discusses the position of the United States in relationship to other developed countries on these measures. Terminology Women often informally discuss their personal feelings about the timing of the pregnancies they have had—whether a baby came just a bit too early, whether a pregnancy occurred at a time when it interfered with future plans but would have been wanted at a later time, whether a baby had been desperately sought for several years and was the answer to heartfelt prayers, or whether a pregnancy was not wanted at any time. Some women feel ambivalent or may disagree with their partners, one wanting a pregnancy and the other preferring to wait. Books, movies, dormitory discussions, real-life arguments, pillow talk, and conversations over the back fence focus on the complexities of wanted, unwanted, and mistimed pregnancies. It is difficult, however, to quantify people's feelings and sort them into categories that hold comparable meaning

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--> over time and across varied social groups. When an unmarried high school sophomore reports that her pregnancy occurred too early, her assessment of ''too early" probably means something different from the report of a married engineer who wanted a baby after working for several years but got pregnant her first year on the job. Information on the demography of unintended pregnancy—the subject of this chapter—is dominated by data from the National Survey of Family Growth (NSFG), a federally-sponsored survey that has developed quite specific terminology and definitions to measure "unintended pregnancy." Over the past four decades, a series of questions has been regularly asked of women by this survey and its predecessors, the Growth of American Families surveys and the National Fertility Studies, in an effort to learn more about women's plans and intentions at the time they became pregnant. In these surveys, women are asked about pregnancies during the previous 5 years, including whether contraception was being used at the time the woman became pregnant. The relevant NSFG questions appear in Appendix C, along with additional material on the history and future plans of this survey. On the basis of these questions, pregnancies in the NSFG are defined as intended at conception: wanted at the time, or sooner, irrespective of whether or not contraception was being used; or unintended at conception: if a pregnancy had not been wanted at the time conception occurred, irrespective of whether or not contraception was being used.   Among unintended pregnancies, a distinction is made between mistimed and unwanted: mistimed conceptions are those that were wanted by the woman at some time, but which occurred sooner than they were wanted; and unwanted conceptions are those that occurred when the woman did not want to have any more pregnancies at all.   The labels and terms from the NSFG have many limitations and ambiguities that should be mentioned. First, it is important to emphasize that the NSFG questions are designed to probe feelings at the time of conception, not at the time of birth. This distinction is important because a woman's feelings can change in many ways over the course of pregnancy (Miller, 1974). For example, Poole and colleagues (1994) report that among a sample of low-income women who were queried both early and late in their pregnancies, 12.5 percent reported a positive shift in attitude toward the pregnancy, and 10 percent reported a negative shift. In particular, an unintended pregnancy can result in a much

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--> anticipated birth and a cherished child. To emphasize this critical distinction, this report does not refer to unwanted births, for example, but rather to births resulting from unwanted pregnancies or conceptions; similar precision is used with the term mistimed. The distinctions that the NSFG draws between intended and unintended and between mistimed and unwanted carry important implications. For example, unintended pregnancies are far more likely to end in abortion than intended pregnancies, and births resulting from unwanted conceptions appear to carry particular risks for both mother and child. In Chapter 3, these consequences of unintended pregnancy are discussed in detail. It is also important to note that knowledge about pregnancy intentions derived from the NSFG comes entirely from women. Bumpass (1994) has reported data about partners' preferences, as provided by female respondents in the 1988 National Survey of Families and Households (see also Williams, 1994), noting that in more than one-fourth of the cases in which a woman described a birth as resulting from an unintended pregnancy, she reported that her spouse or partner had either wanted the birth at that time or was indifferent to the timing. Such disagreement may be a factor in the occurrence of pregnancies that women do not intend; this issue of partner interaction is taken up in more detail in Chapter 6. It is also apparent that the NSFG survey questions, and similar ones used in other surveys, are often not able to measure the complicated mix of feelings that can surround pregnancy, as described by recent ethnographic research in particular (Musick, 1993). It is not uncommon to learn from a pregnant woman, for example, that she both did not "intend" to become pregnant but also was not using contraception, or that perhaps she wanted to be pregnant but was less enthusiastic about having a child (Luker, 1975). In Chapter 6, these complexities are explored in detail. Other caveats with regard to the NSFG measures of pregnancy intention have been raised. For example, the questions about intendedness are retrospective, asking about all pregnancies in the preceding 5 years, which may make the answers offered subject to distortion and recall error. The questions do not distinguish how many months or years pregnancy timing was off, nor do they reflect the intensity of the woman's feelings about the timing of conception. In commenting on data sources other than the NSFG, Chapter 3 and Appendix G also address these generic problems in measuring the intention status of a given pregnancy, noting in particular that the difference between an intended and an unintended conception is often more complicated than these terms imply. Well aware of these nuances, the 1995 NSFG cycle will use an elaborate approach to establishing the intendedness of a given conception (see Appendix C), recognizing that the concept of intended versus unintended is more a continuum than an either/or matter. Consistent with the new approach being taken by the NSFG,

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--> one of this report's recommendations is that researchers develop more refined and differentiated measures of intention status that can accommodate important concepts like ambivalence, denial, and confusion and that can address the feelings of men and couples as well as individual women (Chapter 9). These various caveats about the NSFG measures are not meant to suggest that this national survey and other similar ones fail to capture important information about intention at the time of conception. In fact, despite errors at the individual level, the general validity of the aggregate levels and trends in these measures has been repeatedly demonstrated. The same questions have been used with older and younger women as well as married and unmarried women and across a period of years, ranging from the time before legal abortion became widely available in the 1970s through to the 1990s. In addition, very few women are unable to answer the series of questions; less than 1 percent fall into a residual "undetermined" category. If there is any bias in the NSFG on the issue of intendedness, available evidence indicates that the direction of this bias would be in underreporting unintended pregnancy (Ryder, 1985). That is, the NSFG data may well provide overestimates of intended pregnancies and underestimates of unintended pregnancies. Finally, three other important limitations in the data available from the NSFG should be noted. First, most research and analysis regarding pregnancy intention are based on the 1988 NSFG, which is by now somewhat dated, predating in particular the introduction and use of both injectable and implantable hormonal contraceptives. Nonetheless, the 1988 survey remains a highly credible source of information on intention status.1 Although there was a telephone reinterview of the 1988 NSFG sample in 1990, it reported a less-than-optimal response rate, and thus its results are used sparingly in this report. The next NSFG survey, being completed in 1995, will provide more current data to extend the rich information already available. Second, the marital status groupings used by the NSFG in its fertility questions have changed over the years. For example, the 1965 and 1970 National Fertility Studies were conducted only among currently married women. It was not until the 1973 NSFG that separated, divorced, and widowed women were also queried along with currently married women. From 1982 on, however, the NSFG has sampled all women aged 15–44, irrespective of marital status. 1   The 1988 National Maternal and Infant Health Survey also collected data on intention status. Although these data are briefly referred to in this report, they were not relied on as heavily as the NSFG because they are not part of a long-standing series and therefore cannot provide the perspective of trends over time.

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--> Third, it is widely recognized that the NSFG underreports abortion. Many unintended pregnancies are resolved by abortion, as discussed later in this chapter;2 therefore, if one wants to know, for example, how many pregnancies were unintended in a given year, data on the number of both births unintended at conception and the number of abortions would be needed—data that the NSFG does not have in full measure. Jones and Forrest (1992) suggest that the number of abortions reported in the 1988 NSFG represents only 35 percent of the number actually obtained. Important attempts have been made to supplement the NSFG data with more complete abortion information in order to provide an understanding of the overall level of unintended pregnancy (Forrest and Singh, 1990). The NSFG remains the key data set, however, for tracking the intention status of births, providing comprehensive information on the families in which such births occur and on many other issues as well. Percentage Rates of Unintended Pregnancy Figure 2-1 shows the best available estimate of the percentage of pregnancies that are unintended. These data are based on the 1988 NSFG, supplemented by abortion data from 1987 compiled by The Alan Guttmacher Institute and the Centers for Disease Control. As that figure shows, in 1987, 57 percent of all pregnancies were unintended at the time of conception. This figure of 57 percent includes pregnancies that were aborted as well as both mistimed and unwanted pregnancies that led to live births.3 Only 43 percent of all pregnancies in that year were intended at conception and resulted in live births.4 2   Much research in this field tacitly assumes that all pregnancies ending in abortion were unintended at the time of conception. Although this is accurate as a general finding, it is important to acknowledge that some very small portion of abortions are obtained for pregnancies that were intended at conception, but subsequently became problematic because of the diagnosis of a serious genetic defect in the fetus, for example, or some other troubling turn of events (Torres and Forrest, 1988). This dynamic, however, affects only a small percentage of abortions and does not change the overall estimates presented in this report. 3   Miscarriages are excluded from this analysis and all others in this report because the number of pregnancies ending in miscarriage is not well established and because there is no information on the distribution of miscarriages by intention status. 4   These data are generally consistent with information beginning to emerge from the 1988 National Maternal and Infant Health Survey, which also examined the intention status of births to both married and unmarried women (Kost and Forrest, 1995).

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--> Figure 2-1 All pregnancies by outcome, 1987 (miscarriages excluded). Source: Forrest JD. Epidemiology of unintended pregnancy and contraceptive use. Am J Obstet Gynec. 1994;170:1485–1488. Figure 2-2 is limited to unintended pregnancies only (i.e., intended pregnancies are not included), showing the outcomes of these pregnancies. One striking fact that this figure reveals is that more than half of all unintended pregnancies ended in abortion in 1987. The figure also shows that the majority of births from unintended pregnancies were from mistimed rather than unwanted pregnancies.

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--> Figure 2-2 Unintended pregnancies by outcome, 1987 (miscarriages excluded). Source: Forrest JD. Epidemiology of unintended pregnancy and contraceptive use. Am J Obstet Gynec. 1994;170:1485–1488. In absolute numbers, these proportions mean that in 1987, of the 5.4 million pregnancies that were estimated to have occurred, 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.

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--> Women at Risk of Unintened Pregnancy In analyzing which women contribute to this pool of unintended pregnancies, it is helpful to begin with the profile of women "at risk" of such pregnancies. The definition of women at risk of unintended pregnancy is multifacted. They are women who (1) have had sexual intercourse; (2) are fertile, that is, neither they nor their partners have been contraceptively sterilized and they do not believe that they are infertile for any other reason; and (3) are neither intentionally pregnant nor have they been trying to become pregnant during any part of the year.5 In 1990, about 31 million women met these criteria and could therefore be considered at risk of unintended pregnancy (Table 2-1). These 31 million women represented about half of the 62 million women in the reproductive age range, defined as ages 13–44. Not surprisingly, among women of reproductive age, the highest proportions at risk of unintended pregnancy are found at ages 18–29, the age range in which most women are fertile, have usually begun sexual activity but often prefer to delay pregnancy, and are generally too young to seek sterilization (Figure 2-3). Seventy percent of women in this age category are at risk of unintended pregnancy. This proportion drops dramatically among women age 30 and over, many of whom have been sterilized or have partners who have been sterilized. Nevertheless, nearly 12 million women aged 30–44 remain at risk of unintended pregnancy, compared with nearly 17 million women aged 18–29. Within these various age categories, economic status clearly affects the level of risk (Table 2-1). The association between the proportion of women at risk of unintended pregnancy and economic status varies with the age of the woman. Among females aged 13–19, a higher proportion of teens from families in poverty are at risk, primarily because of earlier initiation of sexual activity among low-income teens. Among teens aged 15–17, for example, 46 percent of those with incomes below the poverty level were at risk of unintended pregnancy, compared with about a third of teens with family incomes 2.5 times the poverty level or above. On the other hand, among women in their 20s, slightly higher proportions of affluent women are at risk (three-fourths of women 2.5 times the poverty level or more versus two-thirds of women below the 5   The concept of being "at risk" of unintended pregnancy is a complicated one with several definitions. For example, much of the research on contraceptive use summarized in Chapter 4 uses a definition in which only women who have been sexually active in the last 3 months are included in the pool of at risk, whereas the definition used here refers to sexual activity at any previous time. Moreover, other researchers suggest that even those women who have never had intercourse at all should sometimes be considered at risk. For example, young adults who have never had sexual intercourse but who are involved in increasingly intimate relationships may, in fact, be at risk of unintended pregnancy.

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--> TABLE 2-1 Number of Women Aged 13–44 and Estimated Number and Percentage of Women at Riska of Unintended Pregnancy, by Age, According to Poverty Status, 1990 (in 1,000s)   No. of Women by Poverty Statusb       Age Group Total <100% 100–184% 185–249% >249% All women           Total 61,808 9,242 8,841 7,638 36,087 13–14 3,226 551 561 457 1,657 15–17 4,875 819 753 611 2,692 18–19 3,777 8,854 585 431 1,907 20–29 19,963 3,689 3,213 2,620 10,441 30–44 29,967 3,329 3,729 3,519 19,390 Women at risk           Total 30,508 4,897 4,300 3,593 17,719 13–14 271 63 47 38 123 15–17 1,734 374 273 221 866 18–19 2,644 646 411 301 1,286 20–29 14,099 2,440 2,153 1,743 7,763 30–44 11,762 1,374 1,417 1,290 7,681 Women at risk as percentage of all women         Total 49.4 53.0 48.6 47.0 49.1 13–14 8.4 11.4 8.4 8.3 7.4 15–17 35.6 45.7 36.2 36.2 32.2 18–19 70.0 75.6 70.2 69.9 67.4 20–29 70.6 66.1 67.0 66.5 74.4 30–44 39.2 41.3 38.0 36.7 39.6 a   Women "at risk" of unintended pregnancy are those who (1) have had sexual intercourse; (2) are fertile, that is, neither they nor their partners have been contraceptively sterilized and they do not believe that they are infertile for any other reason; and (3) are neither intentionally pregnant nor have they been trying to become pregnant during any part of the year. b   Poverty status as based on 1989 family income. Note: Numbers may differ slightly between tables because of rounding. SOURCE: Henshaw SK, Forrest JD. Women at Risk of Unintended Pregnancy, 1990 Estimates: The Need for Family Planning Services, Each State and County. New York, NY: The Alan Guttmacher Institute; 1993.

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--> Figure 2-3 Proportion of women in age groups at risk of unintended pregnancy. Source: Henshaw SK, Forrest JD. Women at Risk of Unintended Pregnancy, 1990 Estimates: The Need for Family Planning Services, Each State and County. New York, NY: The Alan Guttmacher Institute; 1993. poverty level). Among women aged 30–44 in all income groups about 4 in 10 are at risk of unintended pregnancy. The proportion of women at risk of unintended pregnancy varies only slightly by race and ethnicity (data not shown). Non-Hispanic blacks and Hispanics are somewhat more likely to be at risk (52 percent for both groups) than non-Hispanic whites (49 percent). No similar data are available for Native or Asian Americans.

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--> Women Who Have Unintended Pregnancies As noted above, the most recent data show that 57 percent of all pregnancies were unintended at the time of conception (Figure 2-1). This number includes pregnancies that were aborted, as well as both mistimed and unwanted pregnancies that led to live births. Only 43 percent of all pregnancies were intended at conception and resulted in live births. Women of all socioeconomic, marital status, and age groups contribute to this pool of unintended pregnancies, as shown in Table 2-2. (This table displays pregnancies by both intention status and outcome for several demographic groupings, and also includes the actual number of pregnancies involved in each demographic category.) As this table shows, even among currently married women, 4 in 10 pregnancies were either mistimed or unwanted. However, the incidence of unintended pregnancy varies substantially by marital status, age, and economic group, being higher among unmarried and low-income women and among women at either end of the reproductive age span. (Variations in unintended pregnancy according to patterns of contraceptive use are discussed in Chapter 4.) Pregnancies during the teen years are particularly likely to be described as having been unintended. In 1987, for example, 82 percent of the pregnancies experienced by teenagers aged 15–19 were unintended, as were 61 percent of the pregnancies experienced by women aged 20–24.6 Similarly, among women over age 40, 77 percent of the pregnancies experienced were unintended, as were 56 percent of the pregnancies to women aged 35–39. However, even among women between the ages of 25 and 34, between 42 and 45 percent of all pregnancies were described as having been unintended when they occurred. Marital status, which is highly correlated with age, is also strongly related to whether a pregnancy is unintended. The vast majority of pregnancies to never-married women—88 percent—are unintended. Moreover, 69 percent of the pregnancies among formerly married women are unintended. Nonetheless, even among currently married women, 4 in 10 pregnancies are unintended, as noted earlier. Economic status is also strongly correlated with pregnancy intention. Among women whose family incomes fell below the poverty level in the 1988 NSFG, 75 percent of pregnancies were described as unintended, compared with 64 6   Part of the unintended pregnancy phenomenon in adolescence and the early 20s may reflect the decreasing age of menarche and the rising age of first marriage, both of which, taken together, have lengthened the period during which pregnancies are particularly likely to be considered unintended. In 1890, for example, the average number of years between menarche and marriage was 7.2 years (menarche at about 15.5 years of age and marriage at about 22 years of age); in 1988 the interval was almost 12 years (menarche at about 12.5 years and first marriage at about 24 years of age) (The Alan Guttmacher Institute, 1994:Figure 1).

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--> Figure 2-7 Percentage of births in the preceding 5 years to never-married women aged 15–44 by intention status at conception, 1982–1990. Source: Centers for Disease Control and Prevention, National Center for Health Statistics. National Survey of Family Growth 1982 and 1988. Telephone Reinterview; 1990 (preliminary data), unpublished tables. unwanted pregnancies, which carry particularly serious risks (Chapter 3). Table 2-3 shows data on the intention status of births to ever-married women (which excludes the important group of never-married women) broken out by both income and by race (black, white) over the period 1973–1988. The intention status of births among ever-married women below the poverty level followed the same pattern as that of all ever-married women from 1973 to 1988; that is, the proportion of births derived from unintended pregnancies decreased from 1973

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--> TABLE 2-3 Intention Status at Conception of Births in the Last 5 Years to Ever-Married Women and to Ever- Married Women with Incomes Below the Poverty Level, by Race, 1973–1988 (in Percent)   Births Derived from Intended Pregnancies Births Derived from Mistimed Pregnancies Births Derived from Unwanted Pregnancies Group 1973 1982 1988 1973 1982 1988 1973 1982 1988 All ever-married women 61.7 68.3 64.7 24.0 24.0 25.0 14.3 7.7 10.3 Below poverty, ever-married women 48.6 56.6 45.0 25.3 31.5 34.3 26.1 11.9 20.7 Ever-married white women 64.3 69.7 65.6 23.4 23.6 25.6 12.3 6.7 8.8 Below poverty, ever-married white women 53.4 58.8 45.3 27.5 31.0 37.3 19.1 10.2 17.4 Ever-married black women 40.6 56.0 51.0 28.9 28.1 26.2 30.5 15.9 22.8 Below poverty, ever-married black women 35.9 47.5 37.6 20.3 31.5 27.1 43.8 21.0 35.3   SOURCE: Williams LB, Pratt WF. Wanted and unwanted childbearing in the United States: 1973–1988. Advance data from Vital and Health Statistics, no. 189. Hyattsville, MD: National Center for Health Statistics; 1990.

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--> to 1982 and then increased in 1988. Following trends in unwanted pregnancies, however, reveals more dramatic changes. Although births from unwanted pregnancies among all ever-married women showed a slight increase between 1982 and 1988 (increasing from about 8 to 10 percent), births among women below poverty in this group registered much steeper increases (rising from about 12 to 21 percent). This means that by 1988 one of every five births to ever-married women below the poverty level was the result of an unwanted pregnancy—a level approaching the 1973 level of one in four, with most of the progress in the interim having effectively been erased. For black women below poverty, the trend is more pronounced. In 1973, 44 percent of births among this group resulted from an unwanted pregnancy; by 1982, this percentage had dropped to 21 percent. By 1988, however, this number was sharply up again, to 35 percent; thus, in 1988, about one birth in three to ever-married black women below poverty was due to an unwanted pregnancy. As noted above, these figures exclude data for never-married women, who are known to have very high proportions of births that were either mistimed or unwanted at conception (see Figure 2-7). Accordingly, it is reasonable to believe that the proportion of births unwanted at the time of conception among all women below poverty is probably even higher than the levels noted in the preceding paragraph, which is addressed only to those below poverty who have ever been married. The Role of Abortion Reflecting the high proportion of pregnancies that are unintended, U.S. abortion rates are also high. That is, the nation's high abortion rate can be viewed as reflecting high levels of unintended pregnancies. More than a million and a half abortions occurred in the United States every year during the 1980s; in both 1991 and 1992, the total number was about 1.5 million (Figure 2-8). As already shown in Figure 2-2, over half of all unintended pregnancies end in abortion. Factors That Affect Who Obtains an Abortion Among women experiencing unintended pregnancies, marital status has a strong effect on the proportion obtaining an abortion (Table 2-2). Indeed, the proportion of unintended pregnancies terminated by abortion ranges from 75 percent among never-married women to 53 percent among formerly married women and 26 percent among currently married women. Whether the pregnancy was unwanted or mistimed does not affect the proportion of pregnancies ending

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--> Figure 2-8 Number of reported abortions and rate of abortions per 1,000 women aged 15–44, United States, 1973–1992. Source: Henshaw SK, Van Vort J. Abortion services in the United States, 1991 and 1992. Fam Plann Perspect. 1993;26:100–106. in abortion; 51 percent of mistimed pregnancies and 50 percent of unwanted pregnancies end in abortion (Forrest, 1994). The more critical factor is whether or not the woman is married. Compared with marital status, age is a less powerful predictor of the propensity to abort an unintended pregnancy (Table 2-2). About half of women under age 35 who experience an unintended pregnancy obtain an abortion. The proportion rises among older women, with nearly 6 in 10 women ages 40–44 who experience an unintended pregnancy obtaining an abortion. The proportion of women obtaining an abortion in the event of an unintended pregnancy is slightly lower among affluent women than low-income women. But, again, the effect of poverty status is weak and irregular compared with the very strong effect of marital status. International Comparisons International comparisons help to put many of these numbers into perspective. Data from other industrialized democracies demonstrate that the rate of unintended pregnancy experienced among teenagers in the United States is

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--> considerably higher than that in other countries and is often higher for adults as well (Jones et al., 1988, 1985). Figure 2-9 compares the level of intended and unintended pregnancies in the United States with the levels in a number of other industrialized nations.10 It is apparent from Figure 2-9 that the rate of intended pregnancy11 was fairly constant across countries, ranging only between 1.18 and 1.39 pregnancies per woman. However, there is substantial variation across nations in the unintended pregnancy rate, with only France having rates of unintended pregnancy comparable to those found in the United States. Levels of 0.28 in The Netherlands, 0.63 in Great Britain, 0.79 in Canada, and 0.80 in Sweden illustrate that a variety of nations have achieved rates of unintended pregnancy that are considerably less—some a great deal less—than the level of 1.31 in the United States. The information in Figure 2-9 is obviously dated; nonetheless, it clearly suggests that lower rates can be achieved in the United States. U.S. Abortion Rates Versus Other Western Democracies Although the U.S. abortion rate has declined slightly since the early 1980s (Figure 2-8), the rate remains high compared with that in other Western democracies.12 Table 2-4 depicts the abortion rate (number of abortions per 1,000 women aged 15–44) for a number of developed industrialized nations. Compared with those nations, the U.S. abortion rate is two to four times higher. Few other Western democracies have abortion rates that even approach those of the United States; the U.S. rate is more than 50 percent higher than the 10   If all unintended pregnancies were prevented, it is not the case that the total fertility rate would be as low as is implied by the intended pregnancy rate, because many unintended pregnancies are mistimed and would occur later as intended pregnancies. 11   The intended pregnancy rate is derived from the total pregnancy rate. The total pregnancy rate is the average number of pregnancies (i.e., births plus abortions) that a woman would have, assuming a continuation of current age-specific rates over her reproductive lifetime. This rate can be broken down into the planned (or intended), unplanned (or unintended), and abortion rates by applying the distribution of births by planning and intention status to the levels of fertility and abortion that prevailed in the year following the survey. 12   The term "Western democracies" is used in this section to clarify that the comparisons being made are between the United States and selected European countries, plus Canada. Other nations, such as China, the former Soviet Union, countries in Eastern Europe, and some developing countries report ratios of abortions to live births that are significantly higher than those in either the United States or in other Western democracies.

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--> TABLE 2-4 Abortion Rates per 1,000 Women Ages 15–44 by Country, 1980, 1985–1991 Country 1980 1985 1986 1987 1988 1989 1990 1991 1992 Australia 13.9 15.6 16.4 16.3 16.6 — — — — Belgium — 7.5 — — — — — — — Canada 12.6 11.3 11.2 11.3 11.6 12.6 14.6 14.7 14.9 Denmark 21.4 17.6 17.7 18.3 — — 18.2 — — Finland — 12.4 — 11.7 — — 11.5 — — Francea 15.3 14.6 13.9 13.3 13.2 — — — — Federal Republic of Germany (former)a 6.6 6.1 6.3 6.6 6.3 5.6 5.8 — — Irelandb 4.8 5.2 5.2 4.8 5.0 4.9 5.4 — — Italya 18.7 16.8 16.0 15.3 15.3   12.7 — — The Netherlandsc 6.2 5.1 5.3 5.1 5.1 5.1 5.2 — — New Zealand 8.5 9.3 10.5 11.3 12.8 12.9 14.0 14.4 — Norway 16.3 16.3 17.1 16.8 17.1 17.9 16.7 — — United States 29.3 28.0 27.4 26.9 27.3 26.8 27.4 26.3 25.9 United States, whitesd 24.3 22.6 21.8 21.2 21.2 20.9 21.5 20.3 — a   Statistics for France, Germany, and Italy may be incomplete. b   Abortion is illegal in Ireland and the reported rate is based on abortions obtained in England and Wales by women reporting Irish addresses. c   Data from The Netherlands are for residents only. d   Data for whites in the United States include most hispanic women. SOURCES: The Alan Guttmacher Institute. Unpublished data. 1994. Henshaw S, Morrow E. Induced Abortion: A World Review, 1990 Supplement. New York, NY: The Alan Guttmacher Institute; 1990. Henshaw S, Van Vort J. Abortion services in the United States, 1991 and 1992. Fam Plann Perspect. 1993;26:100–106: Table 1. Canadian Center for Health Information. Therapeutic Abortions, 1991. Ottawa, Ontario: Statistics Canada; 1993. United Nations. Abortion Polices: A Global Review, Vol. I. New York, NY: Department of Economic and Social Development, United Nations; 1992. United Nations. Abortion Policies: A Global Review. Vol. II. New York, NY: Department of Economic and Social Development, United Nations; 1993.

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--> Complete Table on previous page.

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--> Figure 2-9 Total pregnancy rate and its components, the intended pregnancy rate and the unintended pregnancy rate, selected countries, selected years. Note: The total pregnancy rate is the average number of pregnancies (i.e. births plus abortions) that a woman would have, assuming a continuation of current age-specific rates over her reproductive lifetime. This rate can be broken down into the planned (or ''intended"), unplanned (or "unintended") and abortion rates by applying the distribution of births by planning/intention status to the levels of fertility and abortion that prevailed in the year following the survey. Source: Henshaw SK, Van Vort J. Abortion services in the United States, 1991 and 1992. Fam Plann Perspect. 1993; 26:100–106.

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--> Norwegian rate, for example. The abortion rate for U.S. whites is also presented to confirm that the higher U.S. rate is not explained by the higher incidence of abortion among minority women in the United States. The data show that the U.S. abortion rate is higher than the rate found in other Western nations among whites as well as among all U.S. women. A detailed study conducted by The Alan Guttmacher Institute comparing the United States with four other comparable areas illustrates the degree to which the U.S. abortion rate reflects the high proportion of pregnancies that are unintended. In the United States, women were estimated to have a total pregnancy rate (defined in Footnote 11) of 2.6—that is, an average of 2.6 pregnancies during their reproductive years. This represents a considerably higher total pregnancy rate than that found in the other study areas: 1.7 in The Netherlands, 1.7 in Quebec, 2.0 in Great Britain, and 2.1 in Ontario. The higher total pregnancy rate in the United States is due entirely to the higher rate of unintended pregnancies (births resulting from unintended pregnancies plus abortions). And even though many unintended pregnancies are resolved by abortion, the rate of births derived from unintended pregnancy is still higher in the United States than in any of the other study areas. Moreover, compared with the four study countries, the U.S. abortion rate remains two to four times higher, as in the earlier comparison (Table 2-4). Conclusion Unintended pregnancy is common in the United States; the most recent estimate is that almost 60 percent of all pregnancies are unintended, either mistimed or unwanted altogether. Reflecting the high proportion of pregnancies that are unintended, abortion rates are also high; about half of these unintended pregnancies are aborted. Although unintended pregnancies occur among women of all socioeconomic, marital status, and age groups, unmarried and poor women as well as women at either end of the reproductive age span are especially likely to become pregnant unintentionally. During the 1970s and early 1980s, a decreasing proportion of births (as distinct from pregnancies) were unintended at the time of conception; between 1982 and 1988, however, this trend reversed such that the proportion of births that were unintended at conception increased. These trends in the 1980s reflect both an overall increase in the proportion of unintended pregnancies and a decline in the proportion of unintended pregnancies that were resolved by abortion. Some data from the 1990s suggest that the proportion of births that were unintended at conception has continued to increase into this decade. In 1990, 44 percent of all births were the result of unintended pregnancy; among such subpopulations as women in poverty, black women, never-married women, and unmarried teenagers, the percentage of births resulting from unintended

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--> pregnancy was substantially higher (59, 62, 73, and 86 percent, respectively, in the late 1980s). International comparisons show that U.S. women experience more unintended pregnancies—and therefore more abortions as well as births—than women in many other industrialized countries. Such data suggest that lower rates of unintended pregnancy could be achieved in the United States. References The Alan Guttmacher Institute. Sex and America's Teenagers. New York, NY and Washington, DC; 1994. The Alan Guttmacher Institute. Unpublished data. 1994. Armstrong KA, Kenen R, Samost L. Barriers to family planning services among patients in drug treatment programs. Fam Plann Perspect. 1991;23:264–271. Bumpass L. Unpublished data tabulated for the Institute of Medicine Committee on Unintended Pregnancy, October, 1994. Canadian Center for Health Information. Therapeutic Abortions, 1991. Ottawa, Ontario: Statistics Canada;1993 Centers for Disease Control, National Center for Health Statistics. National Survey of Family Growth 1982 and 1988. Telephone Reinterview; 1990 (preliminary data). Centers for Disease Control and Prevention. Health risk behaviors among adolescents who do and not attend school—United States, 1992. MMWR. 1994;43:129–132. Forrest JD. Epidemiology of unintended pregnancy and contraceptive use. Am J Obstet Gynec. 1994;170:1485–1488. Forrest JD, Singh S. The sexual and reproductive behavior of American women, 1982–1988. Fam Plann Perspect. 1990;22:206–214. Henshaw SK, Forrest JD. Women at Risk of Unintended Pregnancy, 1990 Estimates: The Need for Family Planning Services, Each State and County. New York, NY: The Alan Guttmacher Institute; 1993. Henshaw S, Morrow E. Induced Abortion: A World Review, 1990 Supplement. New York, NY: The Alan Guttmacher Institute; 1990. Henshaw SK, Van Vort J. Abortion services in the United States, 1991 and 1992. Fam Plann Perspect. 1993;26:100–106. Jones EF, Forrest JD. Underreporting of abortion in surveys of U.S. women: 1976 to 1988. Demography. 1992;29:113–126. Jones E, Forrest JD, Goldman N, Henshaw SK, Lincoln R, Rosoff J, Westoff CF, Wulf D. Teenage pregnancy in developed countries: Determinants and policy implications. Fam Plann Perspect. 1985;17:53–62. Jones E, Forrest JD, Henshaw S, Silverman J, Torres A. Unintended pregnancy contraceptive practice and family planning services in developed countries. Fam Plann Perspect. 1988;20:53–67. Kost K, Forrest, JD. Intention status of U.S. births in 1988: Differences by mother's socioeconomic and demographic characteristics. Fam Plann Perspect. 1995;27:11–17.

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--> Luker K. Taking Chances: Abortion and the Decision Not to Contracept. Berkeley and Los Angeles, CA: University of California Press; 1975. Miller WB. Relationships between the intendedness of conception and the wantedness of pregnancy. J Nerv Ment Dis. 1974;159:396–406. Musick JS. Young, Poor and Pregnant: The Psychology of Teenage Motherhood. New Haven, CT: Yale University Press; 1993. Piccinino L. Unintended pregnancy and childbearing in the United States: 1973–1990. Advance Data from Vital and Health Statistics. Hyattsville, MD: CDC, NCHS; Forthcoming. Poole VL, Klerman LV, Goldenberg RL, Cliver SP. Pregnancy intendedness and maternal behaviors in a low-income high risk population. Unpublished manuscript. University of Alabama at Birmingham; 1994. Ryder NB. The structure of pregnancy intervals by planning status. Popul Stud. 1985;39:193–212. Torres A, Forrest JD. Why do women have abortions? Fam Plann Perspect. 1988;20:169–176. United Nations. Abortion Polices: A Global Review, Vol. I. New York, NY: Department of Economic and Social Development, United Nations; 1992. United Nations. Abortion Policies: A Global Review, Vol. II. New York, NY: Department of Economic and Social Development, United Nations; 1993. Westoff CF. The decline of unplanned births in the United States. Science. 1976;191:38–41. Williams LB. Determinants of couple agreement in US fertility decisions. Fam Plann Perspect. 1994;26:169–173. Williams LB, Pratt WF. Wanted and unwanted childbearing in the United States: 1973–1988. Advance data from Vital and Health Statistics, no. 189. Hyattsville, MD: National Center for Health Statistics; 1990.