9
Conclusions and Recommendations

The facts in this report should be distressing to all Americans. In 1988, the latest year for which complete data are available, almost 60 percent of all pregnancies in this nation were unintended, a percentage higher than that found in several other Western democracies. Unintended pregnancy is not just a problem of teenagers or unmarried women or of poor women or minorities; it affects all segments of society. For example, currently married women and those well beyond adolescence report sobering percentages of unintended pregnancy: in 1987, about 50 percent of pregnancies among women aged 20–34 were unintended, 40 percent of pregnancies to married women were unintended, and more than three-fourths of pregnancies to women over age 40 were unintended. The percentage of pregnancies that are unintended is, however, even higher among some other groups. In 1988, for example, 82 percent of pregnancies among teenagers were unintended, as were 88 percent among never-married women.

During the 1970s and early 1980s, a decreasing proportion of births were unintended at the time of conception. Between 1982 and 1988, however, this trend reversed and the proportion of births that were unintended at the time of conception began increasing. This unfortunate trend appears to be continuing into the 1990s. In 1990, about 44 percent of all births were the result of unintended pregnancy; the proportion is close to 60 percent among women in poverty, 62 percent among black women, 73 percent among never-married women, and 86 percent among unmarried teenagers.

The consequences of these high levels of unintended pregnancy are serious, imposing appreciable burdens on children, women, men, and families. A woman with an unintended pregnancy is less likely to seek early prenatal care and is more



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--> 9 Conclusions and Recommendations The facts in this report should be distressing to all Americans. In 1988, the latest year for which complete data are available, almost 60 percent of all pregnancies in this nation were unintended, a percentage higher than that found in several other Western democracies. Unintended pregnancy is not just a problem of teenagers or unmarried women or of poor women or minorities; it affects all segments of society. For example, currently married women and those well beyond adolescence report sobering percentages of unintended pregnancy: in 1987, about 50 percent of pregnancies among women aged 20–34 were unintended, 40 percent of pregnancies to married women were unintended, and more than three-fourths of pregnancies to women over age 40 were unintended. The percentage of pregnancies that are unintended is, however, even higher among some other groups. In 1988, for example, 82 percent of pregnancies among teenagers were unintended, as were 88 percent among never-married women. During the 1970s and early 1980s, a decreasing proportion of births were unintended at the time of conception. Between 1982 and 1988, however, this trend reversed and the proportion of births that were unintended at the time of conception began increasing. This unfortunate trend appears to be continuing into the 1990s. In 1990, about 44 percent of all births were the result of unintended pregnancy; the proportion is close to 60 percent among women in poverty, 62 percent among black women, 73 percent among never-married women, and 86 percent among unmarried teenagers. The consequences of these high levels of unintended pregnancy are serious, imposing appreciable burdens on children, women, men, and families. A woman with an unintended pregnancy is less likely to seek early prenatal care and is more

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--> likely to expose the fetus to harmful substances (such as tobacco or alcohol). The child of an unwanted conception especially (as distinct from a mistimed one) is at greater risk of being born at low birthweight, of dying in its first year of life, of being abused, and of not receiving sufficient resources for healthy development. The mother may be at greater risk of depression and of physical abuse herself, and her relationship with her partner is at greater risk of dissolution. Both mother and father may suffer economic hardship and may fail to achieve their educational and career goals. Such consequences undoubtedly impede the formation and maintenance of strong families. In addition, an unintended pregnancy is associated with a higher probability that the child will be born to a mother who is adolescent, unmarried, or over age 40—demographic attributes that themselves have important socioeconomic and medical consequences for both children and adults. Pregnancy begun without planning and intent also means that individual women and couples are not able to take full advantage of the growing field of preconception risk identification and management, nor of the rapidly expanding knowledge base regarding human genetics. Moreover, unintended pregnancy leads to approximately 1.5 million abortions in the United States annually, a ratio of about one abortion to every three live births. This ratio is two to four times higher than that in other Western democracies, in spite of the fact that access to abortion in those countries is often easier than in the United States. Reflecting the widespread occurrence of unintended pregnancy, abortions are obtained by women of all reproductive ages, by both married and unmarried women, and by women in all income categories; in 1992, for example, less than one-fourth of all abortions were obtained by teenagers (Centers for Disease Control and Prevention, 1994). Although abortion has few long-term negative consequences for women's health, resolving an unintended pregnancy by abortion can often be a sobering and emotionally difficult experience that no woman welcomes. In addition, the political and social tensions surrounding abortion in the United States continue to be a divisive force at the national, state, and local levels. Recently, these tensions have taken a violent turn, as exemplified by the murder of several individuals associated with clinics that perform abortions. A New Social Norm The committee has found that the extent and consequences of unintended pregnancy are poorly appreciated throughout the United States. Although considerable attention is now focused on teenage pregnancy and nonmarital childbearing, and controversy over abortion continues, the common link among all these issues—pregnancy that is unintended at the time of conception—is essentially invisible. As a consequence, most proposed remedies ignore the common

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--> underlying cause or address only one aspect of the problem and a few vulnerable groups (such as young unmarried women on welfare) are singled out for criticism. The committee has concluded that reducing unintended pregnancy will require a new national understanding about the extent and consequences of this problem. Accordingly, the committee urges, first and foremost, that the nation adopt a new social norm: All pregnancies should be intended; that is, they should be consciously and clearly desired at the time of conception.   This goal has three important dimensions. First, it is directed to all Americans and does not target only one group. Second, it emphasizes personal choice and intent. And third, it speaks as much to planning for pregnancy as to avoiding unintended pregnancy. This last point is particularly significant. Bearing children and forming families are among the most meaningful and satisfying aspects of adult life, and it is in this context that encouraging intended pregnancy is so central. The data presented in this report clearly indicate that the lives of children and their families, including those now mired in persistent poverty and welfare dependence, would be strengthened considerably by an increase in the proportion of pregnancies that are purposefully undertaken and consciously desired. To begin the long process of building national consensus around this norm, the committee recommends a multifaceted, long-term campaign to (1) educate the public about the major social and public health burdens of unintended pregnancy; and (2) stimulate a comprehensive set of activities at the national, state, and local levels to reduce such pregnancies. The campaign should emphasize the fact that reducing unintended pregnancy will ease many contemporary problems that are of great concern. Childbearing by both teenagers and unmarried women would decline, and abortion in particular would be reduced dramatically. At the same time, however, it is important to help the public understand that even if it were possible to eliminate all unintended pregnancies among both teenagers and unmarried women, there would continue to be large numbers of such pregnancies, because it is not only these groups who contribute to the pool. For example, of all births from 1986 to 1988 that were unintended at conception, only 21 percent were to teenagers. The campaign should also target national leaders and major U.S. institutions, as well as individual men and women. The problem of unintended pregnancy is as much one of public policies and institutional practices as it is one of individual behavior, and therefore the campaign should not try to reduce unintended pregnancies only by actions focused on individuals or couples. Although

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--> individuals clearly need increased attention and services, reducing unintended pregnancy will require that influential organizations and their leaders—corporate officers, legislators, media owners, and others of similar stature—address this problem as well. As noted above, the committee calls for a campaign that is both multifaceted and long-term, emphases that derive from the data presented in Chapters 4 through 7 showing that no single factor accounts for unintended pregnancy and that the underlying issues are very complex. In truth, there are many antecedents to the problem: socioeconomic, cultural, educational, organizational, and individual. Therefore, only a comprehensive effort will succeed in reducing unintended pregnancy, as has been the case for other national campaigns, such as those to reduce smoking, limit drunk driving, and increase the use of seat belts. Unintended pregnancy will not be reduced appreciably, the committee believes, unless more individuals and institutions make a major commitment to resolving this problem. Similarly, the campaign must be long-term. Past experience teaches that brief, intermittent efforts to address important social and public health challenges have very limited success. The U.S. Department of Health and Human Services, through its National Health Promotion and Disease Prevention Objectives, has urged that the proportion of all pregnancies that are unintended be reduced to 30 percent by the year 2000 (U.S. Department of Health and Human Services, 1990). The committee endorses this goal, and stresses that it is a realistic one, already reached by other industrialized democracies. Achieving this goal would mean, in absolute numbers, that each year there would be more than 200,000 fewer births that were unwanted at the time of conception and about 800,000 fewer abortions annually as well. The Campaign to Reduce Unintended Pregnancy What should the campaign emphasize? Should it stress contraceptive services? School-based information? Abstinence? parent-child or male-female communication about contraception? Community norms regarding reproductive behavior? The specific skills required to use reversible methods? Or, to put these questions in a slightly different way, which factors best predict unintended pregnancy and should therefore be the main targets of action? The information presented throughout this report, past experience in the public health sector with complex health and social issues, and common sense itself are all helpful in sorting through various options. The committee proposes a portfolio of activities to prevent unintended pregnancy that, like many public health campaigns, emphasizes basic information and preventive services accompanied by comprehensive program evaluation and research. It also addresses the important domain of personal feelings and relationships

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--> The committee recommends that the campaign to prevent unintended pregnancy stress five core goals broadly applicable to men as well as women and to older individuals as well as teenagers: 1.   improve knowledge about contraception, unintended pregnancy, and reproductive health in general; 2.   increase access to contraception; 3.   explicitly address the major roles that feelings, attitudes, and motivation play in using contraception and avoiding unintended pregnancy; 4.   develop and scrupulously evaluate a variety of local programs to reduce unintended pregnancy; and 5.   stimulate research to (a) develop new contraceptive methods for both women and men, (b) answer important questions about how best to organize contraceptive services, and (c) understand more fully the determinants and antecedents of unintended pregnancy.   Before describing these five goals in more detail, it is important to comment on one particular aspect of contemporary American life that may influence the course of the recommended campaign. Over the last decade and more, the age of first intercourse has been steadily dropping, whereas the age of first marriage has been steadily rising, such that there is now an increasing gap between the two events; moreover, there has also been a significant increase in nonmarital childbearing and cohabitation (Bumpass et al., 1991)—trends that are not unique to the United States and are, in fact, widely shared by many other countries. Nonetheless, such trends represent major social and cultural changes in the United States and stand in stark contrast to values that were widely shared, at least in theory, throughout much of this century, such as female celibacy before marriage and the unacceptability of young teenagers being sexually active, let alone "living together." There are many signs that the United States is struggling to come to terms with these new trends and realities. Things are not the way they used to be, but this diverse nation cannot yet seem to agree on what the new rules should be, particularly in the area of sexual behavior. Most probably agree that human sexual expression is a normal and central part of both individual pleasure and species survival, yet the serious issues and repercussions arising from sexual relationship—unintended pregnancy and sexually transmitted diseased (STDs), in particular—remain difficult to discuss, and in many instances they are considered controversial. Some urge that we turn back the clock and try to restrict sexual activity to marriage; others espouse a new ethic of sexual activity that emphasizes personal freedom and pleasure, finding little that is worrisome even about childbearing out of wedlock; still others stake out positions somewhere between

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--> these first two, trying to make room for nonmarital sexual activity under certain circumstances, but frowning on nonmarital childbearing, for example. Concern about this underlying disagreement led the committee to three observations. First, the polarizing arguments about sexual activity have obscured common goals that many share, such as the desirability of all children being born into welcoming families who have planned for them and celebrate their arrival. Focusing on this common ground might help to foster a less adversarial, more tolerant environment, and thus make it easier to discuss contraception candidly and to organize a coherent set of intervention programs that are widely understood and supported. It would be particularly helpful if more people understood that the United States does not differ appreciably from many other countries in its patterns of sexual activity, but it does report higher levels of unintended pregnancy. Second, abstinence cannot be counted on as the major means to reduce unintended pregnancy. Most of the men and women at risk of unintended pregnancy are beyond adolescence and many are married (Chapter 2), and for this large majority, the primary prevention strategy should be increasing contraceptive use. However, the committee unequivocally supports abstinence as one of many methods available to prevent pregnancy. Furthermore, it urges that young teenagers be counseled and encouraged to resist precocious sexual involvement. Sexual intercourse should occur in the context of a major interpersonal commitment based on mutual consent and caring and on the exercise of personal responsibility, which includes taking steps to avoid both unintended pregnancy and STDs. In this context, it is important to add that the committee did not define the age or life stages at which sexual behavior is appropriate; such decisions are matters best left to family, religious bodies, and other social and moral institutions. This issue is at the heart, however, of the disagreement described above. Third, it is critically important that officials at all levels of government and public life not misinterpret or over-react to opposition regarding the strategies to reduce unintended pregnancy that are articulated in this report. Although there are some who object, for example, to comprehensive, high-quality sex education in schools or to helping all sexually active individuals gain access to contraception, these are minority views in many communities and they should not be allowed to paralyze efforts to mount major public health campaigns, such as the one outlined here. One other comment should be made. Even if all five of the campaign elements outlined above and discussed in detail below were put into place, some number of unintended pregnancies would continue to occur. This is because many contraceptive methods have appreciable failure rates even under the best circumstances, and the individuals who use them are not always as careful as is required for maximum efficacy. In addition, there will still probably be some couples who take the risk of using no contraception at all for a period of time, despite having no clear desire

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--> to become pregnant. For those women who become pregnant unintentionally, access to both high-quality prenatal care as well as to safe abortion is needed in order to present women and couples with a range of options for managing the pregnancy. Unfortunately, access to both services is limited, especially in some areas of the country (Institute of Medicine, 1988; Henshaw and Van Vort, 1994), a situation that requires focused attention, advocacy, and resolution. Restricted access to safe, legal abortion, in particular, is often associated with maternal mortality and morbidity, as was the case before the full legalization of abortion in the United States over two decades ago (Institute of Medicine, 1975). Recent reports from Romania further underscore the horrors that women face when they must live in an environment that fails to provide accessible, medically safe termination of pregnancy (The Lancet, 1995). Campaign Goal 1: Improve knowledge about contraception, unintended pregnancy, and reproductive health. The first focus of the campaign to reduce unintended pregnancy should be to increase knowledge about contraception, unintended pregnancy, and reproductive health generally. The evidence summarized in Chapter 5 indicates that individuals of all ages are poorly informed about these issues. The fact that many people mistakenly believe that childbearing is less risky medically than using oral contraceptives and that so few providers or consumers know about emergency contraception are sobering examples of this problem. Misinformation can impede the careful and consistent use of contraception, particularly because many reversible methods in particular require considerable skill to be used properly. Although knowledge alone is often insufficient to increase contraceptive vigilance, it can be viewed as a necessary precondition to other actions needed to reduce unintended pregnancy. The committee recommends that the national campaign to reduce unintended pregnancy include a wide variety of strategies for educating and informing the American public about contraception, unintended pregnancy, and reproductive health in general. These activities should be directed to more than just adolescent girls, highlighting the common occurrence of unintended pregnancy among women age 20 and over, and especially among those over age 40 for whom an unintended pregnancy may carry particular medical risks. They must also include messages for boys and men, emphasizing their stake in avoiding unintended pregnancy, the contraceptive methods available to them, and how to support their partners' use of contraception, along with related material on their  

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--> responsibility for the children they father and the importance of fathers in child development.   The specific inclusion of boys and men in this recommendation deserves special emphasis. As this report has noted repeatedly, males are too often excluded from reproductive health campaigns, even though they often exert great influence on their partners' use of contraception or are themselves active contraceptors. The need to engage males in reproductive health issues is also underscored by the material reviewed in chapter 7 on violence and nonconsensual sex as contributors to unintended pregnancy. Comprehensive education about human sexuality should stress respect for girls and women and the essential role of consent and caring in human relationships, including sexual ones. The data also point to a need for more adult supervision of adolescents, especially young girls, in order to decrease opportunities for coercive or precocious sexual activity. Parents, families, and both religious and community institutions should be major sources of information and education about reproductive health and family planning, especially for young people, and they should be supported in serving this important function. Schools also help to provide education and information on these topics. Although large majorities of Americans support family life and sex education in the schools, many communities have poor-quality programs or none at all. Sex education is mandated in 47 states, but only 3 states include coverage of contraception at both the junior and the senior high school levels, and condoms are mentioned only in five state curriculum guides (Chapter 5). The topic of family life and sex education in the schools has been controversial in some communities; in particular, there is considerable concern that sexual activity may be increased by direct discussion of sexual behavior and contraceptive use. The available data suggest the contrary. In Chapters 5 and 8, for example, the point is made that many adolescents become sexually active before having had any formal family life or sex education. Data are also summarized suggesting that there is insufficient evidence to determine whether abstinence-only programs are effective. However, several studies have shown that sexual activity in young adolescents can be postponed and that use of contraception can be increased once sexual activity has begun by comprehensive education that includes several messages simultaneously: the value of abstinence at young ages especially, the importance of good communication between the sexes and with parents regarding a range of interpersonal topics including sexual behavior and contraception, skills for resisting pressure to be sexually active, and the proper use of contraception once sexual activity has begun. The committee recommends that all U.S. school systems develop comprehensive, age-appropriate programs of family life and

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-->   sex education that build on the emerging body of data regarding more effective content, timing, and teacher training for these courses. State laws and policies should be revised, where necessary, to allow and encourage such instruction.   One component of such courses should stress the magnitude and consequences of unintended pregnancies, and how both males and females can avoid such pregnancies over a lifetime (e.g., through reversible contraception and sterilization, as well as abstinence). Instruction on contraception should include specific information on where to obtain contraceptives, how much they cost, and where to receive subsidized care if expense is a problem. Care should be taken to discuss all available forms of contraception, including emergency contraception as well as such longer-acting, coitus-independent methods as intrauterine devices and hormonal implants and injections. Instruction should include specific material on the details and mechanics of contraceptive use, emphasizing the fact that using many forms of contraception carefully and consistently requires specific skills. Material should also explain the value of using a condom and a female contraceptive method simultaneously to reduce the risk of both unintended pregnancy and contracting an STD. The committee was impressed by the material suggesting that one of the main information and education sources in the nation—the media—is not helping in the task of conveying accurate, balanced information regarding contraception and sexual behavior, and too often highlights the risks rather than the benefits of contraception. Moreover, the electronic media especially continue to emphasize enticing, romantic, and "swept away" sexual encounters among unmarried couples. Only rarely do they present sexual activity in a manner that supports responsibility, respect, caring and consent, and protection against both unintended pregnancy and STDs. Many television executives decline to advertise contraceptive products because they fear controversy; at the same time, they air advertisements that routinely use sexual innuendo to help sell consumer products and programs that are peppered with sexual activity of all types. The committee recommends that the electronic and print media help to educate all Americans about contraception, unintended pregnancy, and related topics of reproductive health. The media should present accurate material on the risks and benefits (including the non-contraceptive benefits) of contraception and should broaden messages about preventing STDs to include preventing unintended pregnancy as well. Media producers, advertisers, story writers, and others should also review carefully the overall amount and content of the sexual activity portrayed in the media and balance current entertainment programming so that sexual activity is preceded by a mutual understanding of both partners regarding its possible

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-->   consequences and is accompanied by contraception when appropriate. Similarly, advertising of contraceptive products and public service announcements regarding unintended pregnancy and contraception should be more plentiful.   There is reason to be optimistic about enlisting the help of the media to reinforce messages about preventing unintended pregnancy. Over the last decade and more, programming has increasingly avoided the portrayal of smoking or drinking as glamorous, high-status activities, and seat belt use by actors in many movies and on television has increased significantly. In enlisting the help of the media in preventing unintended pregnancy, it will be important to ensure that any media-based social marketing efforts are theory-based, long-term, and carefully evaluated. Campaign Goal 2: Increase access to contraception. The second focus of the campaign to prevent unintended pregnancy should stress increasing access to contraception, especially the more effective methods that require contact with a health care professional. The committee was persuaded that one of the reasons for such high rates of unintended pregnancy in the United States is that, through a combination of financial and structural factors, the health care system in the United States makes access to prescription-based methods of contraception a complicated, sometimes expensive proposition. Private health insurance often does not cover contraceptive costs; the various restrictions on Medicaid eligibility make it an unreliable source of steady financing for contraception except for very poor women who already have a child; and the net decline in public investment in family planning services (especially those services supported by Title X of the Public Health Service Act), in the face of higher costs and sicker patients, may have decreased access to care for those who depend on publicly-financed services. Condoms, the most accessible form of contraception, provide valuable protection against STDs but must be accompanied by other contraceptive methods (preferably those that require a prescription) to afford maximum protection against unintended pregnancy. Unfortunately, other accessible nonprescription methods such as foam and other spermicides neither prevent the transmission of STDs nor offer the best protection against unintended pregnancy. The two recommendations that follow take different approaches to increasing access to contraception: reducing financial barriers and broadening the pool of health professionals and institutions that promote pregnancy planning. These reflect the committee's conclusion that financial barriers may limit access to prescription-based methods of contraception, especially for low-income women, and that, overall, there are too few health professionals who actively promote

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--> contraception and pregnancy planning (Chapter 5). As is the case for the first recommended campaign goal—increasing knowledge—the committee views access to contraception as a basic first step toward reducing unintended pregnancy—a necessary precondition, and a fundamental requirement. The committee recommends that financial barriers to contraception be reduced by: (1) increasing the proportion of all health insurance policies that cover contraceptive services and supplies, including both male and female sterilization, with no copayments or other cost-sharing requirements, as for other selected preventive health services; (2) extending Medicaid coverage for all postpartum women for 2 years following childbirth for contraceptive services, including sterilization; 1 and (3) continuing to provide public funding—federal, state and local—for comprehensive contraceptive services, especially for those low-income women and adolescents who face major financial barriers in securing such care.   The first part of this recommendation addresses the need for contraceptive services to be covered more adequately by health insurance, as is increasingly the case for such other preventive intervention as immunizations. Mandates at the federal or state level would accomplish this goal quickly; it may also be possible to move in the needed direction by educating and encouraging all purchasers of health insurance to select policies that offer comprehensive coverage of contraceptive services and supplies. The second and third elements in the recommendation above speak to the major role that such public financing programs as Title X and Medicaid have played in helping millions of people secure contraception, especially those who are young or poor. The Title X program in particular also has a long history of offering general health care to many low-income women, over and above family planning services, because in some communities, there are few alternative providers of primary care. Moreover, the clinical guidelines developed by the program, especially its protocols for annual visits, have helped to set a standard of care for both public and private gynecologic services. The program also laid the foundation for payment to county public health clinics as providers of direct services to the poor. Although evaluation research has not yet defined the precise effects of either Medicaid or Title X on unintended pregnancy, those studies that have been completed on the effects of publicly-funded family planning services (which 1   Currently, women who are enrolled in Medicaid through some avenue other than Aid to Families with Dependent Children (AFDC) are typically covered for only 60 days postpartum.

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--> Supplemental Food Program for Women, Infants and Children), and well-child and immunization clinics. Third, those who provide social work, employment training, educational counseling, and other social services should be taught (in their initial training as well as through in-service programs) about the importance of talking with their clients regarding the benefits of pregnancy planning and how to do so. • Campaign Goal 3: Explicitly address the major roles that feelings, attitudes, and motivation play in using contraception and avoiding unintended pregnancy. Although increasing knowledge about and access to contraception (Campaign Goals 1 and 2) are important first steps, they are not enough. The data presented in Chapter 6 suggest that (1) personal and interpersonal factors exert a profound effect on whether and how well contraception is used, (2) using contraception carefully to avoid pregnancy requires strong, consistent motivation, and (3) such motivation is often based on the perception that pregnancy and childbearing, at a given point in time, are less attractive than other alternatives. In truth, avoiding unintended pregnancy is hard to do; it requires steady dedication over time, often from both partners, and specific skills. A significant portion of the unintended pregnancy experienced by low-income adolescents especially may be due to weak or inconsistent motivation to use contraception. Although pregnancy may not be fully intended in this population, there may be insufficient incentives to practice contraception scrupulously; pregnancy is the common result. This dynamic has been observed primarily among adolescents, but it is undoubtedly seen among older individuals as well. Being pregnant and having a child often bring significant psychological and social rewards, and there must be good reason to forego them. These realities pose a great challenge to service providers and educators. For example, those who teach about contraception as well as those who provide it may well need to spend as much time on issues of personal feelings and interpersonal relationships as on the mechanics of contraceptive use. Accordingly, the third element of the campaign to reduce unintended pregnancy should emphasize the importance of motivation in using contraception and avoiding unintended pregnancy and the potent role that social environment can play in shaping such motivation at all ages. In order to increase the careful and consistent use of contraception, the committee recommends that contraceptive services be sufficiently well funded (through adequate reimbursement rates, increased public-sector support, or both) to include extensive counseling—of both partners, whenever possible—about the skills  

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-->   and commitment needed to use contraception successfully. Similarly, school curricula and programs that train health and social services professionals in reproductive health should include ample material about the skills that contraception requires and about the influence of personal factors on successful contraceptive use, along with more conventional information about reproductive physiology and contraceptive technology.   The influence of motivation in pregnancy prevention also underscores the importance of longer-acting, coitus-independent methods of contraception (e.g., hormonal implants and injections and, when appropriate, intrauterine devices) because they require only minimal attention once the method is established. Although few women and couples rely on these methods (Chapter 4), their long-term potential for reducing unintended pregnancy is great. When offered with careful counseling and meticulous attention to informed consent, these methods constitute an important component of the contraceptive choices available in this country. They do not, however, protect against the transmission of STDs, which requires that condoms be used also, as noted throughout this report. Earlier recommendations offered specific suggestions for increasing knowledge about and access to contraception; all of these efforts, including augmented provider training, should give special attention to longer-acting, coitus-independent methods. On a broader level, policy leaders need to confront the likelihood that, particularly for those most impoverished, achieving major reductions in unintended pregnancies may well require that other more compelling alternatives to pregnancy and childbearing be available. These alternatives include better schools, realistic expectations that a high school diploma will lead to an adequate income, and jobs that are available and satisfying. Put another way, increasing knowledge about contraception and improving access to it as well may not be enough to achieve major reductions in unintended pregnancy when the surrounding environment offers few incentives to postpone childbearing. This comment is not meant to suggest that unless poverty is eliminated unintended pregnancy cannot be reduced. The point is rather that, in the poorest communities especially, only small reductions in unintended pregnancy will likely be achieved by the usual prescription of ''more education, information and services." In this context, it is important to note that research findings do not support the popular notion that welfare payments (i.e., AFDC) and other income transfer programs exert an important influence on non-marital childbearing. Although the committee has no simple recommendation about how to reduce poverty or its corrosive effects on human behavior, it does offer a modest suggestion.

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--> The committee recommends that, in all of its activities, the campaign to reduce unintended pregnancy should stress the importance of personal motivation and feelings in careful contraceptive use and should highlight the influence of social environment on such motivation. Similarly, the connection between unintended pregnancy and poor social environments should be emphasized more explicitly by academic investigators, journalists and the media, politicians, and other opinion leaders interested in problems of social welfare.   In the section on research below, the committee also notes the need to learn more about the complicated interplay of poverty, motivation, hopes for the future, and their combined effects on contraceptive use and unintended pregnancy. • Campaign Goal 4: Develop and scrupulously evaluate a variety of local programs to reduce unintended pregnancy. One aspect of the committee's work that it found most distressing was how little is known about effective programming at the local level to reduce unintended pregnancy. Given all of the public concern about teenage pregnancy, nonmarital childbearing, AIDS, and high-risk sexual behavior, it is quite remarkable that, even using fairly flexible inclusion criteria, the committee was able to identify fewer than 25 programs whose effects on unintended pregnancy, broadly defined, had been carefully evaluated. This lack of program information indicates that there is great need for research to determine various ways to reduce unintended pregnancy. Accordingly, as the fourth element of the campaign to reduce unintended pregnancy: The committee recommends that public- and private-sector funders support a series of new research and demonstration programs to reduce unintended pregnancy. These programs should be designed to answer a series of clearly articulated questions, evaluated very carefully, and replicated when promising results emerge. The focus and design of these new programs should be based, at a minimum, on a careful assessment of the 23 programs identified by the committee that have been well enough evaluated to provide an understanding of their effects on specific fertility measures related to unintended pregnancy. Evaluation data from these programs support several broad conclusions: (1) even those few programs showing positive effects report only modest gains, which demonstrates how difficult it can be to reduce unintended pregnancy; (2) because

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--> most evaluated programs target adolescents, especially adolescent girls, knowledge about how to reduce unintended pregnancy among adult women and their partners is exceedingly limited; (3) there is insufficient evidence to determine whether "abstinence-only" programs for young adolescents are effective, but encouraging results are being reported by programs with more complex messages stressing both abstinence and contraceptive use once sexual activity has begun; (4) few evaluated programs actually provide contraceptive supplies, which may help to explain the small effects of many programs; (5) only mixed success has been reported from programs trying to prevent rapid repeat pregnancies among adolescents and young women; and (6) virtually none of the evaluated programs attempt to influence the surrounding community environment shaping sexual activity and contraceptive use. The design of these new research and demonstration programs should also reflect four additional themes. First, unintended pregnancies derive in roughly equal proportions from couples who report some use of contraception, however imperfect, and from couples who report no use of contraception at all at the time of conception. Although many individuals move back and forth between these two states over time, it may nonetheless be useful to develop specific strategies for each group, especially for the very high-risk group of nonusers. For example, the former group may benefit particularly from ongoing support and special attention to developing better skills in contraceptive use, whereas the latter group may require a greater focus on underlying psychodynamics and couple interaction. Second, available data suggest that multifaceted programs to reduce unintended pregnancy are particularly effective—i.e., programs that include the actual provision of contraceptive supplies, as well as information, education, case management and follow-up, ongoing support, explicit attention to underlying attitudinal and motivational issues, and specific training in contraceptive negotiation and skills. A third theme that should shape these new programs is the need to develop and test out new ways to involve men more deeply in the issue of pregnancy prevention and contraception. Although there is ever more talk about this idea, little investment in program-based research has been made to investigate the effectiveness of various strategies. Some advocate punitive approaches in order to force boys and men to "act responsibly," whereas others are convinced that carrots, not sticks, are needed. Research can help to develop effective interventions, particularly if experimental interventions address men's different ages, life stages, and cultural and personal preferences. A fourth theme that these programs should explore is how to build community support for contraception. Although contraceptive use is ultimately a personal matter, community values and the surrounding culture clearly shape the actions of individuals and couples. Accordingly, at least some demonstration programs should target both the community and the individual, and some might also work exclusively at the community level. This approach has been used

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--> successfully in other areas such as the development of programs to reduce cardiovascular risk factors, and it would be wise to build on this experience for the problem of unintended pregnancy (Puska et al., 1985). Within these broad themes, several additional issues seem particularly important for attention in a new research and demonstration program directed at reducing unintended pregnancy. These include such questions as: How can women over age 35 and their partners, and especially women over age 40, be reached with information and services to reduce unintended pregnancy? Can more "non-health" settings be used to serve adults, such as places of employment or community centers? What ways are especially useful in correcting the serious misinformation that many Americans apparently hold about the risks and benefits of contraception? How can programs effectively combine messages about abstinence with encouragement to use contraception? Designing and evaluating these programs will be assisted by better and more plentiful state and local data on unintended pregnancy. "Mini" NSFGs would help in this regard and should be included as part of the overall package of new program-based research. State and local data also help to identify areas where unintended pregnancy is especially prevalent and can be valuable supplements to federal surveys. Without new investments in measuring the effectiveness of intervention programs, the nation risks wasting large sums of money on failed strategies. Program evaluation is often expensive and can be difficult to do, but it is essential. At the same time, not every program must be evaluated; only certain model programs need be selected for detailed evaluation, whereas replications of successful models with minor modifications may just need expanded management information systems. Several groups could help to fund the recommended research and demonstration programs. Within the federal government, the Office of Population Affairs, the Maternal and Child Health Bureau, the Centers for Disease Control and Prevention, the Bureau of Primary Care, the Agency for Health Care Policy and Research, and the Behavioral and Demographic Research Branch of the National Institute of Child Health and Human Development all have a potential interest in these issues. State entities and private foundations could take a leadership role as well. • Campaign Goal 5: Stimulate research to (a) develop new contraceptive methods for both men and women, (b) answer important questions about how best to organize contraceptive services, and (c) understand more fully the determinants and antecedents of unintended pregnancy. The fifth and final prong of the recommended campaign emphasizes research. With regard to the first area, the committee, like many other groups,

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--> has concluded that currently available methods of reversible contraception are generally effective but imperfect. Even when used properly, most methods have higher than desired failure rates. Some users balk at a particular method because of its side effects, aesthetic considerations (including whether it interrupts sexual intimacy), or cost. Reliable methods that are highly effective in preventing both pregnancy and STDs are lacking, as are methods that might prevent the spread of STDs but permit pregnancy. Particularly glaring is the lack of effective male methods of reversible contraception other than the condom. Accordingly, the committee supports the recommendations of the Institute of Medicine's Committee on Contraceptive Development (1990:1–5): Currently available contraceptive methods are not well suited to the religious, social, economic or health circumstances of many Americans and, therefore, a wider array of safe and effective contraceptives is highly desirable. … New methods would help men and women meet the changing needs for contraception they face during the different stages of their reproductive lives. … Given the relatively small pool of scientists working in this field … special attention should be given to enhancing the training opportunities for young scientists interested in careers in reproduction and contraceptive development. … Unless steps are taken now to change public policy related to contraceptive development, contraceptive choice in the next century will not be appreciably different from what it is today. As noted earlier, the pervasive importance of personal motivation in contraceptive use underscores the need for more long-acting, coitus-independent methods of contraception. Hormonal contraception via implants and injections has already added important options to the available mix of methods; continuing to refine and improve these methods is essential. There probably is no perfect contraceptive, given the varying needs that both men and women have at different ages and stages of reproductive life, and for the foreseeable future, new methods will be only modest additions to existing options. Nonetheless, even moderate improvements can make an important difference. Developing new contraceptive methods is a key concern of the National Institute of Child Health and Human Development, several foundations, and the pharmaceutical industry as well (Science, 1994). Their combined leadership and funding will remain crucial for progress in this area. The second area of research focuses on learning about how best to organize contraceptive services and highlights the role that health services research can play in reducing unintended pregnancy. Two aspects of such research have already been mentioned: the need for better research on the effectiveness of publicly-supported programs that help to finance contraceptive services and the need for new research and demonstration programs at the community level to learn more about how to reduce unintended pregnancy. Many other important questions need answers as

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--> well: How is access to contraception enhanced or restricted by various managed care arrangements in health care? In which instances is it best to offer contraceptive care as a separate, specialized service and in which cases is it preferable to combine such care with other health services (such as STD services)? Many of the same funding entities noted earlier could also take a leadership role on these and related topics in health services research. The third area of research addresses gaps in knowledge about the complex cultural, economic, social, biological, and psychological factors that lie behind widely varying patterns of contraceptive use and therefore unintended pregnancy. There are two basic reasons for the limited state of knowledge about the determinants and antecedents of unintended pregnancy—one methodological and the other theoretical. The methodological issue centers on the serious design and measurement problems in most of the existing research on determinants and antecedents, as noted throughout this report. For example, numerous definitions of contraceptive use have been employed; studies typically have been conducted with small convenience samples composed of students or low-income clinic patients; and many studies depend on a single predictor with minimal controls for confounding factors. Even those large-scale surveys that have used representative samples and multiple indicators (such as the NSFG) are limited by their heavy emphasis on social and demographic factors to the virtual exclusion of psychosocial and cognitive factors. The theoretical issue, perhaps even more important than the methodological one, is that there is insufficient collaboration across disciplines in research on the determinants and antecedents of unintended pregnancy. Conceptualizations are often shaped by the leanings of the researchers' own discipline. Typically, demographers and sociologists have ignored the psychological underpinnings of contraceptive use and unintended pregnancy, psychologists have overlooked the social and demographic factors at work, and economists have limited themselves to economic influences on fertility. Greater interdisciplinary collaboration will be needed to blend these many perspectives into useful predictive models. Moreover, even though contraception occurs in the context of a social interaction between two partners, few studies have examined men's knowledge, attitudes, and perceptions about contraception and pregnancy; and fewer studies have examined gender differences on these issues. Furthermore, in the majority of studies, data on male involvement have been obtained from the women interviewed, not from men. And little research has been done on couple interaction and decision-making that, for example, explores differing power relationships between the sexes and how age, income, and other status inequities affect both sexual behavior and contraceptive use, and therefore unintended pregnancy. Finally, a new variable has entered into the contraceptive equation: concern for the prevention of STDs, including HIV and AIDS. Although there is an obvious overlap between pregnancy prevention and STD prevention, there are

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--> also important differences. For example, the condom is very effective in preventing the transmissions of many STDs, but it is not as effective as some other methods available for pregnancy prevention. By contrast, oral contraceptives are excellent at preventing pregnancy but offer no protection against STDs. So, when only one method is used, rather than a combination that would maximize protection against both consequences, a judgment of some sort is being made between the relative risk and importance of STDs versus the relative risk and importance of pregnancy. Research on the determinants of contraceptive behavior has yet to integrate this new dynamic into existing theories used to explain varying patterns of contraceptive use or method selection. Although it is unreasonable to think that it is possible to achieve perfect understanding of all the predictors of unintended pregnancy or the relative importance of each, the scientific community could clearly be farther down the road than it is now. There are abundant clues and some important leads, but more research is needed to understand fully why more than half of all pregnancies in the United States are unintended at the time of conception and, in particular, why it is that half of these pregnancies occur among women who did not desire to become pregnant, but were nonetheless using no method of contraception when they conceived. The committee suspects that the effectiveness of intervention programs to reduce unintended pregnancy will remain modest until the knowledge base in this area is strengthened. The material on personal feelings and beliefs summarized in Chapter 6 (especially the ethnographic information on motivation) and the many issues covered in Chapter 7 (particularly as regards the conflicting views and attitudes in American toward sexual behavior, which in turn may impede candid discussion about contraception, among other things) offer intriguing and very appealing explanations for the observed phenomena. Careful multidisciplinary work is needed to elaborate these inquiries and to integrate them with the more traditional explanations of unintended pregnancy, such as inaccessible contraception or insufficient knowledge about contraception and reproductive health. Research is also needed on factors outside of individuals (such as the impact of media messages on the contraceptive behavior of individuals), on factors within couples (such as the relative power and influence of women and men in decisions to use or not use particular methods of contraception), and on the combination of individual, couple, and environmental factors considered together. In all such multivariate research, it will be important to study the determinants of sexual behavior as well as contraceptive use, inasmuch as the two are often intimately connected and may jointly influence the risk of unintended pregnancy. Research in these areas will be enhanced by more refined and differentiated tools to measure the intention status of a given pregnancy. As this report has repeatedly noted, the concept of an "unintended pregnancy" may be too simplistic to capture what is often a complicated set of feelings, frequently

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--> involving ambivalence, denial, and confusion. Moreover, the two partners involved may have quite different views regarding the intendedness of a particular conception—a consideration rarely reflected in existing research on unintended pregnancy. The new questions being used in the 1995 NSFG to probe intendedness represent an important step forward (Appendix C), as does the work of Miller (1992) and other investigators. Additional work along these general lines merits support. Many players can help to lead and finance research on the determinants and antecedents of unintended pregnancy. Within the federal government, various agencies of the U.S. Public Health Service will be key (such as the Behavioral and Demographic Research Branch of the National Institute of Child Health and Human Development and the Centers for Disease Control and Prevention), as will the private foundation community. Campaign Leadership Progress toward achieving the five campaign goals outlined above would be enhanced by the existence of a readily identifiable group whose mission is to lead the suggested campaign. The committee recommends that an independent, public-private consortium be formed at the national level to lead the campaign to reduce unintended pregnancy.   Funding and leadership of this consortium should be provided by private foundations, given their proven capacity to draw many disparate groups together around a shared concern. Members of this consortium should be recruited from the health and education sectors, from private businesses and institutions, and from religious bodies and the media. Researchers and program administrators in reproductive health should be included along with government leaders (federal, state, and local) from both the executive and legislative branches. Experts in community development, employment training, and related fields of social service will be central to the effort as well. Similar groups that have been formed to address equally complex problems include, for example, the Partnership for a Drug-Free America and the National Commission to Prevent Infant Mortality, both of which were constituted with broad representation and, in particular, were successful in stimulating the development of parallel groups at the state and local levels. One sector that could be especially effective in this consortium is the "children's lobby," that is, the many groups that speak on behalf of children and their needs. As this report has documented, unintended pregnancy has far-reaching consequences for children, affecting their health and development in

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--> numerous ways. Although groups representing women's issues—reproductive health in particular—have long been vocal in their support of contraception and pregnancy planning, the groups focused on children's issues have been far less visible, especially the maternal and child health community. The national campaign to reduce unintended pregnancy will need their voices as well, not only because of the substance of this issue but also because children's groups have great political appeal and credibility. <><><><><><><><><><><> This report concludes where it began: unintended pregnancy is frequent and widespread, has significant negative consequences, and is poorly understood as a major public health and social challenge. Reasonable remedies are within reach, and they merit widespread support. All pregnancies should be intended—consciously and clearly desired at conception—and it is our shared responsibility to create a climate that helps the nation achieve this clear goal. References Bumpass L, Sweet J, Cherlin A. The role of cohabitation in declining rates of marriage. J Marriage Fam. 1991;53:913–927. Centers for Disease Control and Prevention. Abortion Surveillance: Preliminary Data—United States, 1992. MMWR. 1994;33:930–932. Henshaw SK, Van Vort J. Abortion services in the United States, 1991 and 1992. Fam Plann Perspect. 1994;26:100–112. Institute of Medicine and Commission on Behavioral and Social Sciences and Education. Developing New Contraceptives: Obstacles and Opportunities. Washington, DC: National Academy Press; 1990. Institute of Medicine. Prenatal Care: Reaching Mothers, Reaching Infants. Washington, DC: National Academy Press; 1988. Institute of Medicine. Legalized Abortion and the Public Health. Washington, DC: National Academy Press; 1975. The Lancet. Editorial. Abortion: One Romania is enough. Lancet. 1995;345:137–138. Miller WB. An empirical study of the psychological antecendents and consequences of induced abortion. J Soc Issues. 1992;48:67–93. Puska P, Nissisen A, Tuomilehto J, et al. The community-based strategy to prevent coronary heart disease: Conclusions from the ten years of the North Karelia project. Ann Rev Public Health. 1985;6:147–193. Science. Special section. Reproduction: New developments. 1994;266:1484–1527. U.S. Department of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC; 1990.

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