8
Programs to Reduce Unintended Pregnancy

Included in the committee's charge was the mandate to ''describe the range of programs that have been organized in the last 10 years or so to reduce the incidence of unintended pregnancy and, to the extent possible, comment on the effectiveness of various approaches." This chapter addresses that charge by examining two types of programs: major national programs that help to finance contraceptive services (e.g., Medicaid and the Title X program) and a variety of community-based programs that have been evaluated. The chapter includes commentary on the possible economic effects of these programs, given the deep policy interest in this issue.

National Programs

Although there is no national program whose primary mission is to reduce unintended pregnancy per se, several activities funded at the federal and state levels have great relevance to unintended pregnancy inasmuch as they help to finance contraceptive services. Approximately $622 million in public funds was spent on contraceptive services in 1990 (Gold and Daley, 1991). Many of these funds flowed through several large, national programs: Medicaid and the Title X Family Planning Program serve the greatest number of women, but the Maternal and Child Health Services Block Grant, the Social Services Block



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--> 8 Programs to Reduce Unintended Pregnancy Included in the committee's charge was the mandate to ''describe the range of programs that have been organized in the last 10 years or so to reduce the incidence of unintended pregnancy and, to the extent possible, comment on the effectiveness of various approaches." This chapter addresses that charge by examining two types of programs: major national programs that help to finance contraceptive services (e.g., Medicaid and the Title X program) and a variety of community-based programs that have been evaluated. The chapter includes commentary on the possible economic effects of these programs, given the deep policy interest in this issue. National Programs Although there is no national program whose primary mission is to reduce unintended pregnancy per se, several activities funded at the federal and state levels have great relevance to unintended pregnancy inasmuch as they help to finance contraceptive services. Approximately $622 million in public funds was spent on contraceptive services in 1990 (Gold and Daley, 1991). Many of these funds flowed through several large, national programs: Medicaid and the Title X Family Planning Program serve the greatest number of women, but the Maternal and Child Health Services Block Grant, the Social Services Block

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--> Grant, community health centers, and migrant and rural health centers also help to provide reproductive health services in various ways.1 Title X of the Public Health Service Act was first authorized in 1970 and serves as the backbone of family planning services for many women in the United States. Title X authorizes project grants to public and private nonprofit organizations for the provision of family planning services to all who need and want them, including sexually active adolescents, but with a priority given to low-income persons. The program is buttressed by a training program for clinic personnel and has some community-based education activities as well. Federal monies are provided directly to state and local family planning providers, and state matching funds are not required. In 1990, more than 4,000 family planning clinics received $118 million in Title X support (Ku, 1993). During the 1980s, federal funding fell dramatically and the clinics became more dependent on state, local, and private resources (Gold and Daley, 1991). These family planning clinics served approximately 4.5 million women in 1991, an increase from 3.8 million women in 1981. The majority of family planning clinic clients are low-income women, and approximately one-third are adolescents. The average proportion of male clients served in family planning clinics is approximately 6 percent (Burt et al., 1994). Medicaid is a national, publicly supported program that provides a unique 90 percent federal matching rate to state expenditures for the family planning care of women enrolled in the Medicaid program. Most public dollars spent on family planning are through the Medicaid program; federal and state expenditures in 1990 were approximately $270 million, serving an estimated 1.7 million clients, of whom 2 percent were men (Gold and Daley, 1991; Ku, 1993). In part because of the expansion in eligibility for pregnant and postpartum women, but primarily because of a rise in the number of people enrolled in Aid to Families with Dependent Children (AFDC), and therefore also in Medicaid, more women began using Medicaid to support contraceptive services in the mid- to late 1980s compared with the number in the 1970s and the early 1980s (Ku, 1993). The impact of Title X and Medicaid, the two largest public programs, on unintended pregnancy has not been clearly defined, although a number of studies have tried to assess the effect of "publicly supported family planning programs" (which typically include the Title X and Medicaid programs) on various fertility 1   Another national program relevant to unintended pregnancy is the contraceptive research and development activities of the National Institute of Child Health and Human Development. The Institute of Medicine (1990) report Developing New Contraceptives, commented extensively on that research program; additional analysis is currently under way through another Institute of Medicine study (Applications of Biotechnology to Contraceptive Research and Development: New Opportunities for Public/Private Sector Collaboration) focused on how to best stimulate research in this important area.

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--> measures, usually pregnancy and birth rates.2 Two major approaches have been used. In essence, the first approach posits a certain level of effect of family planning programs on fertility, and then, with that assumption in hand, goes on to analyze the effects of publicly funded family planning services on various other outcomes, such as overall welfare expenditures. For example, Forrest and Singh (1990b) hypothesized four possible patterns of contraceptive use that might result from a reduction in public support of family planning programs; each pattern produced a different level of unintended pregnancy, among other things. They concluded that had public sources of contraceptive services been unavailable in the late 1970s, low-income women would have had between 1.2 million and 2.1 million unintended pregnancies, rather than the approximately 400,000 unintended pregnancies that did occur in 1982. Using the same underlying assumptions, they also computed various estimates of cost savings that flow from public investments in family planning, as discussed later in this chapter. Similarly, Levey and colleagues (1988) constructed a detailed algorithm that allows one to estimate the impact of varying expenditure levels for family planning services on other state outlays, such as AFDC, in Iowa. The other type of research often relies on state or county data and tries to estimate more directly the actual effect of publicly funded family planning programs on selected fertility measures. One such study, completed in the 1970s, examined fertility levels across various geographic areas to assess the impact of family planning programs. The analysis concluded that "the U.S. family planning program has reduced the fertility of low-income women by helping them to prevent unwanted and mistimed births" (Cutright and Jaffe, 1976:100). Two more recent studies focused on different but closely related outcomes and used the same general methodology. Grossman and Jacobowitz (1981) and Corman and Grossman (1985) clearly documented that organized family planning services reduced both infant and neonatal mortality rates. These gains were probably accomplished, in part, by reducing pregnancies among various groups that are at high risk of such mortality, such as low-income women or those with very short interpregnancy intervals. Because these groups also tend to be at high risk of unintended pregnancy, it is reasonable to suggest that the positive effects observed by these investigators were due in part to reducing unintended pregnancy. Other studies using state level data have also been completed and, in the aggregate, suggest that publicly funded family planning programs affect some fertility measures more than others. For example, Moore and colleagues (1994) 2   This section reviews studies that have assessed the impact of publicly funded family planning services on unintended pregnancy; some of these studies are reviewed again from the perspective of economic impact in a later section of this chapter labeled "The Fiscal Impact of Family Planning Funding."

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--> reported that total public expenditures on contraceptive services (including Medicaid, Title X, and state funds) per woman at risk of unintended pregnancy had no apparent effect on adolescent pregnancy rates, but did seem to have a variable effect on birth rates, differing somewhat by race and age. Singh (1986) also found lower teenage birth rates in states with higher proportions of adolescents served in family planning clinics, but did not find an association with lower pregnancy rates. Similarly, Anderson and Cope (1987) found that publicly funded family planning programs in the United States could be linked to lower birthrates; this analysis did not assess effects on pregnancy rates. Olsen and Weed (1986) also concluded (using 1978 data) that overall enrollment in family planning clinics is associated with reduced teen birth rates, but suggested that such enrollment may also be associated with increased teen pregnancy rates. In a subsequent analysis, these same investigators (Weed and Olsen, 1986:190) seemed to soften their earlier finding by concluding that "greater family planning program involvement does not result in a reduction in teenage pregnancy rates." It is important to add, however, that all of these analyses have some unresolved methodological problems that suggest their conclusions should be viewed carefully. None of them, for example, has been able to control for varying levels of sexual activity, nor do they factor in such other dynamics as the growing use of condoms—widely available outside of organized clinic systems—to prevent pregnancy.3 One of the most recent such investigations is that of Meier and McFarlane (1994). They conducted a state-level analysis to measure the effectiveness of publicly funded family planning during the mid-1980s in influencing a variety of outcomes. The analysis focused on several indicators of effectiveness: the state-level abortion rate, the age-specific fertility rate for adolescents, the incidence of low birthweight and premature births, the proportion of pregnant women receiving late or no prenatal care, and the neonatal and infant mortality rates. The principal measure of public funding was the level of family planning 3   As noted, these studies rely on state-level data, and this choice of analysis unit has both advantages and disadvantages. The disadvantage is that the outcome indicators of effectiveness are not directly linked to program activities or to the behavior of program clients. Viewed from another perspective, however, the use of state aggregates may be a potential strength. As is argued in Appendix G, the evaluation of any given program is greatly complicated when a number of programs coexist in the same geographic area. For instance, the information provided by one program may encourage a potential contraceptive user to seek out the services that are provided by a different program or by the private sector. These cross-program and spillover effects cannot be captured using program data alone; they require histories of program contacts and service utilization on the part of clients. A state-level analysis is implicitly concerned with the net effects of all publicly funded activities, and may therefore provide a truer picture than would emerge from consideration of any one program in isolation.

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--> funding per capita, a measure that draws together all Title X funds as well as funds from other federal and state sources (see Gold and Macias, 1986; and Gold and Daley, 1991, for discussions of these funding sources). They also defined a second and somewhat problematic measure of public funding: the publicly funded abortion rate. This rate is the ratio of publicly funded abortions in a given year to the number of women aged 15–44 in that year. In addition, the investigators included a set of socioeconomic control variables, such as income per capita in the state, the proportion of the population that is black and Hispanic, and the proportion of the population that is Catholic. In a pooled regression analysis, they found that increases in family planning funding were associated with a number of beneficial outcomes, such as a reduction in the incidence of low birthweight and reductions in neonatal and infant mortality levels. These effects were statistically significant and, when translated into totals, demographically important. They also found lower abortion rates, and because abortion is in almost all cases a response to an unintended pregnancy, this study suggests that increases in family planning funding reduced the number of unintended pregnancies. Curiously, there is no apparent association with adolescent fertility rates, nor do significant effects emerge with respect to the proportion of births that are premature or the proportion of women who receive inadequate prenatal care. These conclusions from the analysis of Meier and McFarlane (1994) should be accepted with caution. The regression specification includes the publicly funded abortion rate as an explanatory variable, yet the total abortion rate, to which publicly funded abortions contribute, is treated as one of the dependent variables or effectiveness indicators. Without a reanalysis of these data, it is not possible to say whether their mixing of explanatory and dependent variables renders all conclusions suspect. It would not be surprising, however, if the net effect of the misspecification is to understate the full beneficial impacts of family planning funding. Again, though, none of these studies focus specifically on Title X or Medicaid. This gap in the literature is puzzling and remarkable. It means, in particular, that the largest public sector funding efforts, Title X and Medicaid, have not been well evaluated in terms of their net effectiveness, including their precise impact on unintended pregnancy. At the same time, it is important to acknowledge how difficult it would be to design an evaluation of either program in the aggregate, although studying effects on unintended pregnancy in small areas is possible and should be done. In any event, these programs clearly help to finance contraceptive services for many women (and some men) and there is a strong suggestion that, as part of overall "publicly funded family planning services," they help to reduce fertility. It is unlikely that careful evaluation would find no net effect on unintended pregnancy.

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--> Local Programs Assessing the effectiveness of local programs in reducing unintended pregnancy is also difficult, in part because of the sheer number of programs involved. There are, in fact, hundreds of smaller programs ongoing or recently completed in the United States that in some way address unintended pregnancy, and the committee made no attempt to investigate them all in great detail. Rather, the committee's focus was on those whose results have been carefully evaluated, a focus that considerably narrowed the task. In the subsections below, lessons learned from the evaluated programs are discussed. It is important, however, to begin this consideration of local programs with a clear acknowledgment that the existing array of programs at the local level—those that have been evaluated and those that have not—reflects a unique history and, in particular, the changing interests and ideologies of both public and private funding agencies. Historical Perspective There are few references to adolescent pregnancy in the scientific literature before 1960, although there are many references to births among unmarried women (often called "illegitimacy" at the time). In that era, most researchers and program planners appeared to believe that a child's being born to a married woman, rather than the age of the woman, was the major factor determining pregnancy outcomes and life prospects for mother and child. In the 1960s, however, this began to change. Health, education, and social service practitioners became concerned about the consequences of adolescent pregnancies, and therefore developed programs to assist pregnant adolescents, largely those still under 19 years of age. The emphasis of these early programs was on reducing maternal and infant morbidity and mortality through adequate prenatal care; keeping pregnant adolescents in school during their pregnancies, often through the development of special schools, and returning them to school after delivery of their child; and ameliorating problems in the areas of interpersonal relations, housing, and financial status through the provision of social services. The programs also worked to prevent rapid repeat pregnancies among the participants. Perhaps the first such program was the Webster School, begun in 1963 in Washington, D.C., and funded by the Children's Bureau. Programs in Syracuse, New Haven, Baltimore, and other cities followed, some with federal support, but most with local or, later, state funds. In 1972, Kantner and Zelnik began to publish their pioneering studies of adolescent sexuality, contraceptive use, and pregnancy; and other researchers began to analyze the epidemiology, risk factors, and outcomes of adolescent pregnancy. In 1971 and 1976, federal agencies developed proposals to address the problem of adolescent pregnancy, but no major initiative was undertaken

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--> until the publication in 1976 of The Alan Guttmacher Institute's report, 11 Million Teenagers: What Can Be Done About the Epidemic of Adolescent Pregnancies in the United States? (The Alan Guttmacher Institute, 1976). A federal task force was then assembled, and its report to U.S. Department of Health, Education and Welfare Secretary Joseph Califano led to the establishment of the federal Office of Adolescent Pregnancy Prevention (OAPP). Shortly thereafter, in 1978, the Adolescent Health, Services, and Pregnancy Prevention and Care Act was passed. Although it included prevention language, the primary emphasis of this act was on demonstration projects that would provide "services to adolescents who are 17 years of age and under and are pregnant or who are parents." Several foundations became interested in this problem and supported demonstration programs largely directed at pregnant adolescents (Klerman, 1981). The 1981 federal Omnibus Budget Reconciliation Act effectively terminated the original grant program, but OAPP survived and the Adolescent Family Life Act was passed. The act specified that grants should be made for demonstration projects for the provision of prevention services as well as for care services, and stressed the prevention of sexual activity among adolescents (i.e. abstinence) and adoption as an alternative for adolescent parents. Under the terms of the new legislation, grantees could not provide family planning services, other than counseling and referral, unless appropriate family planning services were not otherwise available in the community (Vinovskis, 1988). The 1981 legislation allowed OAPP to support education programs whose aim was to prevent pregnancy. This was a relatively new role for the federal government since most sex education was assumed to be conducted in schools, by religious organizations, or by families, and the federal role in curriculum development had traditionally been advisory, with state and local governments taking the lead. Between 1978 and 1984, the Center for Health Promotion and Education at the Centers for Disease Control (CDC) supported research on different aspects of sex education programs. This research was an attempt to understand the range of approaches being used around the nation and to determine their effectiveness. During this time, several not-for-profit, intermediary organizations, such as the Center for Population Options and the North Carolina Coalition on Adolescent Pregnancy,4 were organized to advocate for attention to the problem of teenage pregnancy, to act as intermediaries between policymakers and local program 4   Over time, some of these organizations have made name changes. For the sake of clarity, it should be noted that the Center for Health Promotion and Education is now the Division of Adolescent School Health at the CDC; the Center for Population Options is now Advocates for Youth; and the North Carolina Coalition on Adolescent Pregnancy is now the Adolescent Pregnancy Prevention Coalition of North Carolina.

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--> leaders, to perform research and promote networking, and to provide technical assistance to local agencies. Major foundations, notably The Ford Foundation and The Robert Wood Johnson Foundation, provided financial assistance to a variety of community organizations to work with schools to open school-based clinics. The possibility that a school-based health clinic could prevent adolescent pregnancy was first suggested by the results of the St. Paul program in 1980 (Edwards et al., 1980). Many local and state agencies followed this lead and organized such clinics. However, school systems, wary of controversy, usually stressed the need to improve adolescent health generally rather than to prevent pregnancy only. Foundation investments in this field have varied over the years and across individual grant programs, but they, like the government, first stressed care for pregnant and parenting adolescents and then moved gradually to emphasize the prevention of pregnancy among teenagers. The Charles Stewart Mott Foundation, for example, established the Too Early Childbearing Network in 1978. Other large foundations, such as the Carnegie Corporation of New York, The Ford Foundation, and The William T. Grant Foundation, developed demonstration projects to ameliorate the effects of childbearing by adolescents (Klerman and Horwitz, 1992). A more recent move by foundations toward primary prevention programs is exemplified by the development of New Futures and Plain Talk: A Community Strategy for Reaching Sexually Active Youth by the Annie E. Casey Foundation and heavy reliance in the developmental phase of school-based adolescent health centers on the support of The Robert Wood Johnson Foundation. In sum, the existing network of programs around the country reflects a unique history, particularly the early interest in caring for pregnant adolescents, followed by changing ideologies at the federal level. Reducing unintended pregnancy has rarely been a goal of these community-based, local programs, even though their stated goals, such as reducing repeat pregnancies, are often closely related to unintended pregnancy. Program Search and Selection As just noted, few programs at the local level have been explicitly designed to prevent unintended pregnancy. Accordingly, the committee considered those programs whose various outcome measures or stated goals are closely related to reducing unintended pregnancy: (1) raising the age of first intercourse, (2) improving contraceptive use (or, similarly, decreasing unprotected sexual activity), and (3) reducing pregnancy among adolescents, including rapid repeat pregnancy. The committee further decided that to be considered "evaluated," a program must meet the following criteria: (1) the evaluation was completed since 1980;

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--> (2) the evaluation was performed using an experimental or quasi-experimental design; (3) the evaluation measured behavioral outcomes (e.g., sexual activity or contraceptive use); and (4) the evaluation results were published in peer-reviewed journals. With these criteria in mind, the committee conducted a national search to learn, in general, about local programs to reduce unintended pregnancy and, in particular, to identify programs whose results had been evaluated. Letters requesting information were sent to the directors of programs receiving Title X funds and the directors of maternal and child health agencies; federal and local government programs were contacted; foundation officers were queried; the primary investigators of several leading initiatives and the project directors of many smaller initiatives were approached; notices asking for program leads appeared in newsletters of the National Association of County Health Officials and the American Public Health Association and online through the Women's Health Network; and relevant literature was reviewed through MedLine, Social Science Index, Sociological Abstracts, Psychological Abstracts, Popline, and Family Resources databases, as well as the Health Promotion and Education Database from the CDC. This search resulted in the identification of more than 200 programs that in some way address unintended pregnancy. In the aggregate, they represent a wide array of approaches, from school-based condom distribution programs, to classic family planning clinics; from innovative programs of community education to highly targeted interventions to prevent rapid repeat pregnancy among adolescents. Some are well-known and have received significant public attention, such as the "I have a Future" program at Meharry Medical College and the Family Life and Sex Education Program of the Children's Aid Society in New York City. However, only 23 met the committee's evaluation criteria. These programs are a small and unique subset of the many programs now under way that deal with issues of sexual activity and contraceptive use. Nevertheless, because their effectiveness has been assessed carefully, they constitute the available body of knowledge regarding how to intervene effectively at the local level to reduce unintended pregnancy.5 The 23 programs that met the committee's criteria are listed in the following subsection.6 5   Numerous programs to protect against HIV-AIDS have also been organized and evaluated, and they provide additional perspectives on strategies to reduce unintended pregnancy (Kirby et al., 1994; Institute of Medicine, 1988). 6   Results from New Chance and the Summer Training and Education Program have been published, but not in peer-reviewed journals. Nevertheless, they are included here because of their superior evaluation designs.

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--> Evaluated Programs Background information on each program listed below is presented at length in Appendix F, including descriptions of program implementation, objectives, evaluation methodology, results, and primary references. A.   Community of Caring: several sites around the country providing prenatal care for pregnant adolescents, with an emphasis on planning for future goals, including prevention of repeated pregnancy. B.   Condom Mailing Program: direct mail program for adolescent men designed to increase their knowledge about and access to condoms. C.   Elmira Nurse Home Visiting Program: comprehensive program of prenatal and infancy nurse home visitation for low-income women bearing their first child. D.   Facts and Feelings: home-based abstinence program using sex education videotapes to encourage discussion between parents and young adolescents about sexual issues. E.   Girls Incorporated Preventing Adolescent Pregnancy: nationwide sexuality education program divided into four age-appropriate components. F.   Group Cognitive Behavior Curriculum: school-based sexuality curriculum using group cognitive behavior theory to personalize accurate information about sexuality and contraception. G.   McCabe Center: alternative public school for pregnant students providing prenatal and postnatal education, with an emphasis on delaying rapid repeat pregnancy. H.   New Chance: national demonstration program offering comprehensive services for low-income parenting adolescents and young adults. I.   The Ounce of Prevention Fund's Parents Too Soon Program: statewide program for pregnant and parenting adolescents using home visiting and parent groups. J.   Postponing Sexual Involvement: school-based curriculum encouraging middle school students to delay initiation of sexual intercourse in combination with a human sexuality and contraception component. K.   Project Redirection: comprehensive demonstration program targeting pregnant and parenting adolescents age 17 or younger, including an employment-orientation component. L.   Project Taking Charge: school-based program combining abstinence-only sexuality education and vocational education. M.   Reducing the Risk: school-based curriculum (based on several interrelated theoretical approaches) encouraging avoidance of unprotected intercourse through abstinence or contraceptive use. N.   Reproductive Health Screening of Male Adolescents: hospital-based reproductive health counseling for adolescent boys, aged 15–18.  

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-->   O.   School/Community Program for Sexual Risk Reduction Among Teens: community-based program to delay initiation of sexual intercourse and improve use of contraceptives by sexually active adolescents. P.   Self Center: full reproductive health services as well as health education and counseling services provided through a school-linked clinic. Q.   Six School-Based Clinics: school-based clinics providing comprehensive health care to students located in six sites around the country. R.   St. Paul School-Based Health Clinics: one of the first school-based health clinic systems in the country providing comprehensive health care, including reproductive health care. S.   Success Express: school- and community-based program emphasizing abstinence for middle school students. T.   Summer Training and Education Program: summer school program combining work experience with educational skills and information about responsible sexual decision-making. U.   Teenage Parent Demonstration: large-scale field test of a change in welfare rules and services, increasing self-sufficiency through enhanced services. V.   Teen Outreach Project: school-based program involving students in community volunteer service, designed to reduce adolescent problem behaviors. W.   Teen Talk: sexuality education program based on the health belief model and social learning theory, designed to make adolescents aware of the seriousness of adolescent pregnancy and the probabilities of such a pregnancy happening to them. In the remainder of this chapter, reference is often made to ''effective" programs. Given the fact that the 23 programs had many different, albeit overlapping, goals, the actual nature of the effectiveness varies from program to program: that is, some were found to delay the age of first intercourse, some were found to improve contraceptive use, and so forth. For simplicity, the specific outcome measures are not always referred to extensively in the text; however, they are described in more detail in Appendix F, and many of the examples used to illustrate cross-cutting themes are careful to specify what effectiveness means for a given program. It is important to emphasize that these programs are not necessarily effective in achieving their program goals. The committee's criteria asked only that the program be well evaluated, not that it be successful. A Comment on Program Evaluation The fact that only 23 evaluated programs surfaced for detailed review merits comment. The limited number should not be construed as an indication that program managers in the area of reproductive health are uninterested in learning

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--> equal number of pregnancies compared with the number in the comparison group, they had fewer abortions and thus more births. Polit (1989:169) notes that "the larger number of children born to Project Redirection participants could … reflect the failure of the family planning component. The approach taken by program staff in the Project Redirection sites was 'low-key,' one that reflected (at least in part) the discomfort of some staff members about discussing issues relating to sexuality. Such an approach appears to have been insufficient to motivate the participants to use effective contraceptives regularly." New Chance is another example of a program that was not successful in reducing rapid repeat pregnancies among a sample of women who gave birth in adolescence. Program goals included increasing the economic self-sufficiency of adolescent mothers, helping them become effective parents, enhancing the development of their children, and delaying repeat pregnancies. Program participants reported both a higher pregnancy rate and a higher rate of abortion; therefore, comparable rates of repeat childbearing (approximately 25 percent) were found in both intervention and control groups (Quint, Polit, et al., 1994). 7. Little is known from the evaluated programs about how to influence sexual behavior or contraceptive use by changing the surrounding socioeconomic or cultural environment. The objective of most evaluated programs is to affect the actions of individuals by working directly with them rather than by changing the cultural milieu in which they live. No evaluated programs address the sociocultural environment in which sexual decision-making takes place; thus, nothing is known about how, or even whether, to try to influence the surrounding culture as one way of changing sexual and contraceptive behavior. The analysis of the Summer Training and Education Program (STEP) elucidates this point. Program leaders have hypothesized that the failure to seek any major environmental change was one reason for the program's lack of success. STEP combined work experience for adolescents with educational skills and information about responsible sexual decision-making. The evaluation found that although students in STEP gained significant life skills, no significant differences in sexual behavior were noted between the intervention and comparison groups. Walker and Vilella-Velez (1992:64) suggest that this is because no influence was made on "schools, peers, neighborhoods, family, family income, and perceived and real future job opportunities … almost half of the adolescents who dropped out of STEP cited the need for income or other causes in their environment as their primary reason for dropping out of school." A notable exception to the pervasive emphasis on individuals is The Media Project, part of the nonprofit organization Advocates for Youth. Although not included in the 23 evaluated programs, this is one activity that has attempted to change the almost constant barrage of sexually enticing messages presented by the media. To do so, program staff work with, for example, writers, directors, and producers of television soap operas and situation comedies, providing them

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--> with information about responsible sexual behavior, including contraceptive use. The Media Project has not been evaluated in any substantial way. It may well be that community-based programs are not the right mechanism for attempting broad cultural change. These programs are often small, involving a few hundred people or less, and they last only a few years. Programs designed to change individual behaviors may never be able to achieve more than marginal success in a society whose health care system, available information and education, and overall socioeconomic and cultural environments do not uniformly support careful use of the best methods of contraception, as discussed in Chapters 5, 6, and 7. The Fiscal Impact of Family Planning Funding Policymakers are understandably interested in the budgetary impact of public investments in family planning programs, both those that operate at the national level and those that work in states and communities. A series of studies has attempted to assess the net fiscal impact of family planning funding, typically by asking: How does an extra dollar of public funding for family planning affect all public outlays for other health and social services? (The techniques and concepts that are involved in establishing program cost-effectiveness are discussed at length in Appendix G).9 Recent studies of fiscal consequences have been 9   The literature on budgeting effects is sometimes described as being concerned with cost–benefit analysis or with program cost-effectiveness. Neither characterization is correct. The concept of cost-effectiveness is briefly commented on here.     A program is said to be cost-effective relative to another program, or relative to the current state of affairs, if it can be demonstrated to provide the same level of effectiveness at lower total social cost. In general, effectiveness must be described in a number of distinct dimensions, as in the analysis of Meier and McFarlane (1994). No rigorous assessment of cost-effectiveness has been undertaken for U.S. family planning programs.     The assessment of program cost-effectiveness is a demanding task, particularly so with respect to the data that are required to support a rigorous analysis. If these data are not available, evaluation can proceed only on an informal basis by invoking strong assumptions on the nature of the cost functions. Much of the cost-effectiveness literature in family planning has rested on two exceedingly strong yet rarely scrutinized assumptions: (1) that the multiple dimensions of output can somehow be collapsed into a single output indicator and (2) that average costs, defined as total costs divided by (composite) output, are constant over the range of output. If both conditions are met, then a single observation on average costs can provide a basis for program comparisons. But in the absence of supporting evidence—the committee found none in the literature—these strong assumptions are not well justified and may be misleading as a guide to policy.

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--> undertaken by, among others, Levey and colleagues (1988), Forrest and Singh (1990a,b), Vincent and colleagues (1991), Fitzgibbons (1993), Olds and colleagues (1993), and Trussell and colleagues (1995). These studies conclude that public expenditures in support of family planning are more than offset by the savings that are produced in other health and social services spending. Depending on the study, these services include the Medicaid, AFDC, food stamp, and Women with Infants and Dependent Children (WIC) expenditures associated with pregnancy, the medical expenditures associated with abortion or childbirth, and the programs that support low-income mothers and their infants and children. The results of Forrest and Singh (1990b) can serve as an illustration of the nature of the findings in general. According to the authors, "for every government dollar spent on family planning services, from $2.90 to $6.20 (an average of $4.40) is saved as a result of averting [short-term] expenditures on medical services, welfare and nutritional services" (Forrest and Singh, 1990b:6). The range of such estimates found in the literature is great, and the figures depend on details in the assumptions employed and the range of health and social services under consideration. Nevertheless, given the entitlement nature of many of the services in question, family planning efforts would seem to make good sense from the viewpoint of a taxpayer concerned with government budgets (Levey et al., 1988). Before the assumptions and the data that support this conclusion are assessed, a brief preface is in order. The taxpayer's benefit—cost approach, however useful as a device for marshaling political support, is a specialized and, in some respects, rather peculiar metric for evaluation. It frames the evaluation issue very narrowly, being concerned only with the impact of one form of public expenditure on another form. There is no clear or necessary relationship between the claims that programs make on government budgets and their cost-effectiveness or social desirability. A program that, from the social point of view, is so cost-ineffective that it should not be undertaken may nevertheless reduce claims on government budgets. Conversely, a program that is socially beneficial may increase claims on budgets. Thus, the terms benefit and cost that appear in a taxpayer's benefit—cost analysis bear no obvious correspondence to social benefits and costs. Having issued this warning about the interpretation of taxpayer benefit—cost analyses, some of the common features of these studies and avenues for further work can be addressed. Program Reactions to Funding Withdrawal A common assumption in studies of fiscal effects is that the withdrawal of public funding would simply cause the clinics or programs in question to vanish.

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--> Program clients would then need to seek out services elsewhere, and would usually receive services on less advantageous terms. This assumption requires some justification and clarification. First, it envisions an extreme case, in that total funding withdrawal would be a sharp departure from the current state of affairs. If the aim is to predict net fiscal impacts, a safer approach is to predict the impact of a marginal withdrawal of funds, for example, a cutback of 10 percent. Second, no attempt is generally made to predict the reactions of clinics and programs to the withdrawal or reduction of state or federal support. Yet, as the experience of the late 1980s shows (Donovan, 1991), programs faced with declines in external support tend to rely more on fees for service, and may also make adjustments in services they provide and their referral practices. To explore the full consequences, two issues need to be identified: (1) the types of changes in pricing and service delivery that are feasible and how likely the different program reactions may be and (2) how women will react to the new provider prices and characteristics. These issues require, at a minimum, consideration of the price-responsiveness of demand for contraceptive services and reproductive health services more generally. Treatment of Mistimed and Unwanted Pregnancies A recurrent theme in this report is the importance of distinguishing between pregnancies that are mistimed and those that are unwanted. The distinction surfaces here with respect to the fiscal implications of preventing unintended pregnancies. If the pregnancy that is prevented by contraception was unwanted, then its prevention certainly reduces all future claims on Medicaid, AFDC, and the like. If the pregnancy in question was mistimed, however, these claims on budgets may only be deferred into the future. In other words, prevention of a mistimed pregnancy may well reduce claims on this year's budget; it does not necessarily reduce claims on future budgets. Two points are therefore at issue. The first is whether to discount claims on all future budgets attributable to prevention, perhaps expressing the net public sector savings in terms of present values. It may be that when pregnancies are properly timed the likelihood of claims on public programs is much reduced. Discounting is therefore not only a matter of present versus future budgets. It also has to do with individual poverty dynamics and the likelihood that a properly timed pregnancy will coincide with periods of (relatively) high income, that is, income high enough to reduce or eliminate claims on AFDC and other income-conditioned services. The second point concerns the budget period envisioned in the fiscal evaluation. If the fiscal impact question is posed as "do family planning expenditures in this fiscal year reduce claims on budgets in this year and the next?", then it may well be reasonable to aggregate mistimed and

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--> unwanted pregnancies in the analysis. If, on the other hand, the time period envisioned in the analysis is longer, then the distinction between unwanted and mistimed pregnancies should be maintained. If the distinction is not maintained and unwanted and mistimed pregnancies are treated alike, there is the potential for gross overstatement of the public sector savings owing to prevention. Program Eligibility Versus Participation In the United States, far fewer women (or families) than are eligible for them actually participate in public support programs such as AFDC, Medicaid, WIC, and related programs. Yet the fiscal analyses of family planning either assume full participation among all eligible people or assume that a given proportion of eligible women participate irrespective of other socioeconomic characteristics. The first assumption is naive and clearly overstates the potential public sector savings that can be secured by prevention. The second assumption is less severe, but a more refined and informative estimate of public sector savings could be made by taking the socioeconomic characteristics of family planning clients into account. Incomplete Accounting for Public Revenue Effects When a working woman becomes pregnant unintentionally, she may experience at least a short period of withdrawal from the labor market; likewise, a nonworking woman may be discouraged from working as a result of the pregnancy. These labor market consequences result in lower tax revenues, a factor that many studies on fiscal consequences do not consider. The revenue implications extend beyond the period of labor market withdrawal or nonparticipation. When they are out of the labor market, women fail to add to their total labor market experience; this has implications for future earnings and tax payments. If a pregnancy to an adolescent interrupts schooling, human capital formation is also affected, again with lifetime implications for earnings and revenues. These effects have not been taken into account in any systematic fashion in the literature on fiscal consequences. In spite of these caveats, which suggest that the public sector benefits of family planning funding may well have been exaggerated in some studies, the weight of the evidence presented by the several studies cited earlier (i.e., Levey et al., 1988; Forrest and Singh, 1990a,b; Vincent at al., 1991; Fitzgibbons, 1993; Olds et al., 1993; and Trussell et al., 1995) is that public funding of family planning services is likely to reduce net claims on public budgets. The magnitude of such reductions is much in doubt and will remain in doubt until rigorous research can be directed to this topic.

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--> Conclusion It is clear that much effort and many resources at the local, state, and national levels have been applied to programs to affect sexual behavior and contraceptive use, with much attention focused on young women. Although no formal evaluations of the large programs that help to finance or directly provide contraceptive services (such as Title X and Medicaid) have been completed, the support that these programs furnish undoubtedly helps to increase access to contraception, and thereby helps individuals avoid unintended pregnancy. Evaluations of the long-term effects of these programs are sorely needed, but they will be difficult to design. Although there are hundreds of programs at the community level that in some way address sexual or contraceptive behavior related to unintended pregnancy, few have been carefully evaluated, and knowledge is therefore very limited about how local programs can reduce unintended pregnancy. Those that have been evaluated illustrate several cross-cutting themes: because most of the evaluated programs target adolescents, especially adolescent girls, knowledge about how to reach adult women or men is exceedingly limited; there is insufficient evidence to determine whether abstinence-only programs have been effective in increasing the age at first intercourse; sexuality education programs that provide information on both abstinence and contraceptive use neither encourage the onset of sexual intercourse nor increase the frequency of intercourse among adolescents; in fact, programs that provide both messages appear to be effective in delaying the onset of sexual intercourse and encouraging contraceptive use, especially among younger adolescents; even though most of the evaluated programs encourage contraceptive use in some way, there is a notable reluctance to provide program participants with contraceptive methods themselves or to help participants gain access to contraceptive services at some other site; about half of the evaluated programs attempting to reduce rapid repeat pregnancy, especially among adolescents, have been successful; and little is known from the evaluated programs about how to influence sexual behavior or contraceptive use by changing the surrounding socioeconomic or cultural environment.   Finally, the weight of the evidence is that public funding of family planning services is likely to reduce net claims on public budgets. The magnitude of such reductions is much in doubt, and will remain in doubt until rigorous research can be directed to this topic.

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