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CHAPTER 5 Planning for Pregnancy Much of the literature about preventing low birthweight focuses on the per iod of pregnancy--how to improve the content of prenatal care, how to motivate women to reduce risky habits while pregnant, how to encourage women to seek out and remain in prenatal care. By contrast, 1 ittle attention is g iven to opportunities for prevention before pregnancy. Only casual attention has been given to the proposition that one of the best protections available against low birthweight and other poor pregnancy outcomes is to have a woman actively plan for pregnancy, enter pregnancy in good health with as few r isk factors as possible, and be fully informed about her reproductive and general health. This chapter covers three courses of action applicable before conception to reduce the incidence of low birthweight: 1. Developing the notion of prepregnancy consultation to identify and reduce risks associated with poor pregnancy outcomes, including low b~rthweight; emphasizing the importance of r isk reduction in the per lad between pregnancies, particularly for women who have had a poor outcome in a previous pregnancy; and making health professionals more aware of the possibilities in the periods before and between pregnancies for improving the outcome of pregnancy by providing appropr late services, education, and referrals. 2. Enlarging the content of health education related to reproduction, particularly In schools and in family planning settings. 3 . Recogniz ~ ng the contr Button of family planning to reducing the incidence of low birthweight and continuing to expand such services where unmet need remains; and emphasizing the special needs of teenagers and the importance of publicly subsidized family planning services. Pr epregnancy Risk I dent if icat i on and Reduct ion Many of the r isks associated with low birthweight can be recognized in a woman before pregnancy occurs and specif ic interventions can be instituted to deer ease the r isk . Such factor s include: 119

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120 . certain chronic illnesses; smoking; moderate to heavy alcohol use and substance abuse; Inadequate weight for height and poor nutritional status; susceptibility to rubella and other infectious agents; age (under 17 and over 34~; the likelihood of a very short interval between pregnancies; and high parity. For some of these factors, risk reduction before conception may offer more protection than risk reduction during pregnancy. For example, the importance of an adequate diet during the period immediately before pregnancy was made evident by the famine studies of World War II.i Many major maternal chronic illnesses, especially hypertension and diabetes, present a more serious risk to both mother and fetus if the condition is not adequately under control before pregnancy. For example, Fuhrmann et al. found that strict metabolic control initiated before conception in insulin-dependent diabetic mothers was associated with significantly fewer congenital malformations than metabolic control begun after conception.2 Similarly, it is possible that reducing high levels of tobacco consumption before conception exerts more of a protective effect with regard to low birthweight than reduction after conception. And finally, the risk factors of childbearing at extremes of the reproductive age span, brief interpregnancy interval, and high par ity can be managed by family planning to prevent, or more carefully time, the occurrence of pregnancy. Such considerations have led some experts to suggest that more attention be given to preconception counseling aimed at detecting risk factors and intervening, where possible, to reduce them.3 4 Anecdotal and small area reports indicate that informal prepregnancy consultation already occurs in some settings and is used as an opportunity to gather relevant information including historical, physical, and laboratory data; to discuss potential risks before conception occurs; and to refer for specific services ranging from treatment of medical problems to behavioral risk reduction programs, such as smoking cessation activities. These consultations also provide an opportunity to explain the importance of prompt pregnancy diagnosis and early prenatal care and to help ensure that a woman knows where to obtain such services. Prepregnancy consultation and risk reduction are especially important during the interval between pregnancies for women who have experienced a prior reproductive casualty. In Chapters 2 and 3, the associations between certain elements in an obstetric history and subsequent low birthweight deliveries are described. Researchers have found, for example, that the relative risk that a second birth will be ~ ~ is 4.4 if the first birth was premature.6 Accordingly, health professionals in contact with women who have such obstetric histories should give careful attention to risk premature (less than 36 weeks Gestation)

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121 identification and reduction to help increase the chances of better outcomes in future pregnancies. Prepregnancy consultations should be available from a variety of health care providers in different settings. Certainly this counseling is in the practice domain of obstetricians and gynecologists, nurse-midwives, family planning personnel, and family practitioners who provide obstetr ic and gynecologic services . Not all women of reproductive age are in touch with such personnel, however, so referral for prepregnancy consultation should be offered by a wide var iety of health care providers to reach more women at r isk . Education will be r equired to sensitize these providers to the importance of counseling in the interval before pregnancy. Pediatricians, In particular, have an important role to play. In caring for families that have experienced a previous reproductive loss or low-weight birth, pediatricians and other primary care providers can offer counseling about r isk reduction if a future pregnancy is anticipated. A1SO, in working with adolescent girls, pediatr Asians and related health professionals have an opportunity to reduce selected r isks (for example, by immunizing against rubella) and to introduce basic concepts of planning for pregnancy. In urging that pediatricians g ive more attention to r isk identif Cation and reduction among adolescents, the committee recognizes that physician counseling of teenagers is not always successful. However, if such counseling were supported by the many other strategies outlined in this report-- particularly the health education priorities described later in this chapter and in Chapter 9--it is reasonable to believe that effective communication would increase. I t adding ion, more research is needed the area of adolescent health and behavior generally to improve our understanding of how best to work with young people to protect and promote the ~ r health, and to instill concepts of r isk reduction and planning for pregnancy. _ The committee concludes that identifying and reducing r isks before pregnancy can help reduce the incidence of low birthweight. Realizing the benefits of this strategy will require: further elaboration and discussion by the relevant profess tonal groups of the content and timing of such counseling, with particular attention to data on the r isks associated with low birthweight (and other poor pregnancy outcomes) that can be identified and modified before conception; incorporation of such consultations into a wide var. iety of settings to reach as many women as possible; development of written materials for professionals and for women themselves; health services research to monitor the costs and results of such consultations; willingness of third party payers to reimburse such services, once def ined and evaluated; .

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122 . . education of health care providers and other professionals in touch with women of reproductive age about these concepts; determination of the adequacy of health services resources in a given setting to manage problems that are identified through prepregnancy assessment; and additional research on how best to influence the health-related behavior of individuals, particularly teenagers. It should be noted that the approach outlined here assumes a degree of coordination and free flow of information throughout the health care sector that rarely exists. For example, laboratory tests ordered as part of a consultation before pregnancy probably would be repeated once pregnancy is diagnosed if different providers were involved, resulting in significant overall cost increases. Practices of this type should be given explicit attention in the development of programs for risk counseling before pregnancy. The experience of regional perinatal care systems should be reviewed in this context; methods for coordinating data collection and avoiding duplication of effort are an important part of these systems. The committee recognizes that emphasis on risk counseling and reduction before conception raises two troublesome issues. First, it is probably true that the women most likely to benefit from such counseling are those least likely to be in a service system sufficiently organized to provide it. For example, very poor women and the very young often fall completely outside of the health care system. Rather than providing an argument against prepregnancy counseling, this reality lends support to the provision of such counseling and education in multiple settings and by a wide range of health care providers to increase the potential points of contact. Moreover, even if only one segment of the population obtains such consultations initially, the practice could help set a trend that might be adopted widely over time. The second issue raised by the notion of consultation before pregnancy involves the implication that women are always "almost pregnant, n or Improbably pregnant in the future.. For couples desiring pregnancy, such a view may be acceptable, but for a woman not contemplating pregnancy, it could be exceedingly offensive. Such considerations underscore the need for sensitivity and tact in pursuing preconception risk reduction, with regard both to content and timing. Enlarging the Content of Health Education A second strategy in the period before pregnancy is concerned with health education related to reproduction. Education about reproduction, contraception, pregnancy, and associated topics is already provided in a variety of ways: through public information campaigns; in school- based classes, group sessions, lectures, and related printed materials; and in various health care settings. Available data regarding both the

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123 etiology and risks of low birthweight suggest that in all such settings health education related to reproduction should be expanded to include the following s ix topics: 1. the ma jor factors that pi ace a woman at risk of a poor pregnancy outcome, including low b~rthweight; 2. the general concept of reducing specific risks before conception and the advisability of consultation before pregnancy to identify and reduce risks associated with low birthweight; 3. the importance of early pregnancy diagnosis and of early, regular prenatal care, and where to obtain such services; 4. the importance of immunizing against rubella and of identifying other infection-related risks to the fetus; 5. the value of altering behavior to reduce a range of risks associated with low birthweight, including smoking, poor nutrition, and moderate-to-heavy alcohol consumption and substance abuse; and 6. the heightened vulnerability of the fetus to environmental and behavioral dangers in the early weeks of pregnancy, often before pregnancy is suspected or diagnosed. This fact points to the importance of avoiding x-rays, alcohol and drug use, selected toxic substances and similar threats especially in the first trimester.7 Bringing up such topics at the time of pregnancy confirmation-- typically well into the first trimester--is often too late, because fetal development is already well under way. These topics should be incorporated into reproduction-related health education as major themes, not minor addenda. Although the individual topics suggested here probably could be expanded and refined, the central message remains--education about ways to increase the chances of a good pregnancy outcome should not be delayed until after conception. These health education themes should be included in a variety of health care settings, including family planning clinics where many women of reproductive age receive care. Although no comprehensive data exist on the precise content of the education provided in these clinics, anecdotal information suggests that the major--often exclusive-- emphasis is on contraception. Such education should be expanded to include the themes noted above, and national organizations of family planning providers should promote the use of educational mater ials encompassing these themes, particularly for their clients who are considering becoming pregnant. Private providers also should offer comprehensive health education related to reproduction, incorporating these same topics. Of equal impor Lance are the sex education and family life curr icula of schools. Although these issues may be discussed in some settings, the little information available on school-based health education suggests that they are of low priority. Two recent surveys have been conducted on the content of sex education in public secondary schools, but it is doff icult to discern whether the issues detailed above were covered. The topic "pregnancy and ch~ldbear ding" was frequently included in the curricula surveyed, but the precise content of this

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124 topic is not known. Moreover, not all schools have such courses. According to a 1982 survey of almost 200 districts in large U.S. cities conducted by the Urban Institute, one out of four school districts with junior and/or senior high schools offered no sex education in any of its schools.8 9 The committee recognizes that the subject of family life and sex education is controversial in some communities ~ but asserts nonetheless that the need is great for young people to understand fully and accurately human reproduction and family planning, as well as the topics highlighted above. Further, recent polls have demonstrated clear majority support for public school instruction in sex educations Such education must focus on the role of men as well as women in choices about reproduction. Family planning should be a shared responsibility, and education about pregnancy should not be confined to women. A last caveat on this topic of health education. It is well known that mere provision of information frequently is insufficient to change behavior. A full literature review on this subject was not attempted, but several summaries suggest that: (1) educational programs tend to attract those who already have information and are motivated; (2) acquisition of information is not always accompanied by changes in behavior or other outcome measures; and (3) educational programs would be more successful if attention were paid to factors such as support of family, friends, culture, and providers. ~ Health education alone is likely to be of only limited value, but when joined with the other suggestions in this report for reducing the incidence of low birthweight, including the public information approaches descr ibed in Chapter 9, the probability of benefit from such education increases. The come ttee concludes that health education should be an important component of low birthweight prevention. To be more helpful in this regard, the content of such education should be expanded to include discussion of the ma jor r isk factors associated with low birthweight and the importance of early pregnancy diagnosis and prenatal care. Health education should be provided in a variety of settings, particularly in family planning clinics and schools, and be strengthened in the private sector as well. The Role of Family Planning in Reducing Low Birthweight The committee examined the data relating use of family planning services to poor pregnancy outcome, both infant mortality and low birthweight. The close relationship between the two measures (Chapter 1) justifies examination of both sets of data to determine the utility of family planning In reducing low birthweight. Several studies suggest strongly that the reduction in infant mortality in the United States over the past 20 years is due in part to effective family planning. For example, Morris et al. analyzed data from the United States 1960 Live Birth Cohort Study and found that 27 percent of the reduction in infant mortality between 1965 and 1967 was

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125 due to changes in the age and par ity of the mother . They attr ibuted this shift to individual family planning. ~ 2 Similarly, Grossman and Jacobowitz used variations in infant mortality rates among counties in 1971 to study the probable impact of public police es and programs. They found that the increase in the use of organized family planning services by low-income women was the second most important factor, after abortion, i n reducing nonwhite neonatal mortality. The authors believe they may have underestimated the impact of all family planning services because their analyses did not include a measure of services delivered by pr ivate physicians . ~ 3 Thor ne and Green also found a relationship between availability of family planning services and declining per inatal mortality in Maryland, particularly among nonwhites. ~ ~ The evidence that family planning services reduce low birthwe~ght is less complete than for infant mortality, but compelling nonetheless. It derives in part from the notion that family planning has averted a number of high-risk pregnancies, some of which would have resulted in low birthweight infants. For example, family planning services, as well as abortion and sterilization, have decreased childbearing among women with high-risk characteristics such as grand multiparity, chronic severe hypertension, and appreciable heart and renal disease, as well as such demographic risks as age (under 17 and over 34~. Better documentation exists to show that family planning has been especially useful to two populations at increased risk of low birth- weight, low-income women and teenagers. Dryfoos has estimated that 2.4 million low-income women and 1.7 million teenagers in 1978 used the most highly effective reversible methods of contraception and success- fully avoided an unplanned pregnancy. ~ s Zelnik and Rantner have suggested that up to 680 ,000 pregnancies among unmarried, sexually active teenagers between 15 and 19 years of age were averted in 1976 by use of contraceptives. ~ 6 Forrest et al. calculated that in 1979 an estimated 417, 000 unintended teenage pregnancies were prevented by enrollment in publicly financed family planning programs. 7 Family planning also increases the interval between births for many women. Because a very short interval between pregnancies is a r isk factor for low birthweight, family planning practices that reduce this r ~ sk contr ibute to the prevention of low birthweight. Spratley and Taffel reported that 19 .2 percent of the 1977 births occurr ing within 1 year of a previous live birth were of low birthweight, about 3 to 4-1/2 times the proportion observed for longer interb~rth intervals. The percent of infants of low birthweight was lowest when the interval between live births was between 2 and 4 years. ~ ~ The importance of pregnancy interval also is discussed in Chapter 3. The committee explored the notion that family planning could reduce low birthweight by increasing the proportion of pregnancies that are intended and wanted at the time of conception. It is apparent, for example, that both teenagers and unmarried women experience higher than average rates of low birthwe~ght; they also report higher rates of unintended pregnancies. It has been suggested that a woman who has planned for and welcomes her pregnancy probably will adhere to the health practices necessary to increase the chances of a successful

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126 pregnancy outcome.~9 Recent data from the 1980 National Natality Survey support this thesis. In that survey of married women, wanted- ness of pregnancy had a strong relationship to seeking prenatal care . Women who wanted a child at the time they became pregnant were more likely to receive care early in pregnancy than were those who would have preferred to have had a child at a later time. Women who had not planned to have another child showed the most delay in seeking prenatal care. These factors accounted for about a third of the black/white differential in the number of prenatal visits reported.20 Nonethe- less, concepts of intendedness and wontedness of pregnancy, and the relationship of such factors to pregnancy outcome, remain unclear. Problems of definition and methods In conducting research on this topic are large. In sum, although the exact mechanisms and magnitude of effect are not well defined, there does seem to be general agreement that family planning has had a positive impact on infant mortality and probably also on low birthweight. The committee concludes that family planning services should be an integral part of overall strategies to reduce the incidence of low birthweight in infants. Closely related to family planning as a means of fertility regulation is induced abortion. It seems reasonable to examine whether abortion has helped to decrease the overall incidence of low birth- we~ght by, for example, increasing intervals between births and averting childbearing in high-risk individuals. Several studies have tried to assess directly the impact of abortion availability on a range of reproductive outcomes, including low birthweight.22~25 These studies suggest that the significant increase in the availability of abortion between the late 1960s and the mid-1970s contributed to the gradual decline in low birthweight rates over the some period, although the magnitude of the influence has not been well-defined. The issue of the effect of a previous induced abortion on subsequent pregnancy outcome is discussed in Chapter 2. unmet Need for Family Planning The widely recognized value of family planning notwithstanding, it is apparent that such services are not always used for reasons ranging from service inadequacies to the knowledge, attitudes, and practices of women themselves. Three types of evidence can be used to document this assertion: the number of unintended pregnancies, the percentage of women at risk for unintended pregnancies who do not use contraception or obtain family planning services, and the number of abortions. With regard to unintended pregnancies, Dryfoos estimates that 4.4 million women in the United States experienced unintended pregnancies in 1978. These pregnancies resulted from contraceptive failure despite an effective method, use of fewer or ineffective methods, or lack of a method. Her figures also show that during this period about 4 million

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127 sexually active, fecund women were at high risk of an unintended pregnancy because they were using no method or methods with high failure rates. About 1 million of these women were from low-income families and almost 900 ,000 were teenagers. ~ s Evidence of the failure to use contraceptives includes a report by l Torres and Forrest in which they estimate that in 1981 almost 9.5 million low-income women were at risk of unintended pregnancy, but only 58 percent were obtaining family planning services from clinics (about twv~thirds) or private physicians (about one-third}. The corresponding f figure for the other higher isk, underserved grou - -women under age 20--was over 5 million at risk and only 57 percent served, almost equally by clinics and private physicians.26 Because induced abortions often signal the end of an unintended pregnancy, the increasing number of abortions obtained in the United States (more than 1.5 million in 1980) suggests a failure of family planning. Almost 30 percent of those abortions were to women under age 20 . Henshaw and O 'Reilly estimate that 30 percent of pregnancies in 1980 terminated in abortion.2 7 MIFF ~- =] I _ ~ ~^ _~- 7~ "~. "V=^ ~ ~ C`= ~ ~V"~ - ICE "-filly" ~ ~ ~ percent or women under age 20 and 52 percent of women 20 and over who obtained abortions in Illinois in 1980 were using no contraceptive method at the time of conception.28 Clearly, large segments of the population apparently are still in need of contraceptive services. The unmet need is largest among those at particularly high risk for low birthweight, the poor and the young. In 1981, the Alan Guttmacher Institute {AGI) estimated that .9.5 million low income women and 5 million sexually active teenagers needed subsidized (that is, supported at least in part by public funds) family planning care, but over 40 percent of both groups did not obtain medically supervised contraceptive care. .2 9 In this regard, the committee calls attention to the special role of Title X of the Public Health Service ACE, the Family Planning Assistance Program. 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 priority given to low-income persons. The service program is buttressed by a training program for clinic personnel, limited community-based education activities, and evaluation requirements designed to ensure program accountability. In 1981, more than 4.5 million women received family planning services in clinics supported at least in part by Title X money. AGI estimated that more than 800,000 unintended pregnancies--about 425,000 of them Among teenagers--were averted as a direct result of the federally funded family planning program in 1981. AGI suggests that if these unplanned pregnancies had occurred, there would have been an estimated 282,000 additional births and 433,000 more abortions that year ~ the remaining pregnancies would have ended in miscarr Sages); and further, during the 1970s, 2.3 million unintended births were averted because of the federally supported funnily planning progr~'n.29 The merits of the Title X program are reviewed periodically by the U.S. Congress, often as part of the reauthorization process. In such

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128 reviews, the committee urges that the following perspective be kept clearly in mind: The need for subsidized family planning remains significant and federal funds should be made generously available to meet documented needs. With regard to the particular relationship of family planning and low b~rthweight, it is important to stress that both young teenage status and poverty are major risk factors for low birthweight and that Title X is specifically targeted at low income women, including adolescents. AS such, the program should be regarded as an important part of public efforts to prevent low birthwe~ght. By highlighting Title X, the committee recognizes that it appears to underrepresent the enormous contribution made by the private sector and by other public financing and service programs to the provision of family planning to low-income women. The latter category includes Medicaid, the Maternal and Child Health Services Block Grant, the Social Services Block Grant, and state and local government revenues . Several of these sources of public funds are discussed elsewhere in this report. Emphasis in any family planning program should be given to the prevention of unwanted pregnancies in sexually active teenagers, particularly those under 18 who are unmarried. (As noted in Chapter 2, childbearing in early adolescence carries an increased risk of low birthweight, even though such risk appears to derive less from young age itself than from the other r isk factors that accompany teenage childbearing, such as poor educational attainment, low socioeconomic status, and late receipt of prenatal care.) It is well known that more than 50 percent of girls in the United States engage in sexual inter- course before they reach their nineteenth birthdays and that effective contraceptive use in this population is poor.30 Young teenage mothers and their infants are at high risk for a nether of medical and social problems, one of which is low birthweight (Chapters 2 and 31. The vulnerability of the infants of teenagers recently has been examined by McCormick et al. They found that infants born to mothers age 17 and under and to 18- and 19-year-old multiparas had substantially higher low birthweight, neonatal mortality, and postneonatal mortality and morbidity rates than infants born to mothers In their 20s.3~ Such findings underscore the recommendation made above about the value of Title X funds and call further attention to the importance of providing family planning services to teenagers in a manner that is acceptable to this group and therefore used by them. Despite much attention to this issue by groups such as the Planned Parenthood Federation of America, the high rates of teenage pregnancy, abortion, and childbearing in the United States attest to the complexity of the problem. Surveys conducted by Zeinik and Rantner found that, although more teenagers reported using contraceptives in 1979 than in 1976, more than a quarter of premaritally sexually active women 15 to 19 years old

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129 never used contraceptives and almost two-f~fths used them incon- sistently. Moreover, the use of the most effective methods, the pill and the IOD, had declined between the two study years. The committee did not study carefully the issue of how to increase effective contraceptive use among sexually active teenagers; it is a complicated problem around which a large literature and body of program exper fence have developed. For example, Chamie et al . studied counties in which a high proportion of teenagers at risk of unintended pregnancy obtained birth control services in clinics. They found that the clinics in these counties, in contrast to those in low-met-need counties, more often had special activities des ~ gned to recruit adolescents and engaged in follow-up and outreach activities to adolescent clients. All f ive special adolescent clinics were in high-met-need counties. Such clinics were better able to retain teenage clients and more likely to provide services without charge, and to see adolescents without a formal appointment.3 3 Zabin and Clark found that the three most important reasons given by teenagers for choosing a family planning clinic were confidentiality, a staff perceived to care about teens and relate well to them, and proximity. 3 4 Effective use of contraceptives by sexually active teenagers is likely to increase as a result of family planning services organized along the lines suggested by such studies. Complementary strategies, some of which are noted in this chapter and elsewhere, include absence of financial barriers to care; widely available family life and sex education in schools and communities, beginning in junior high school at the latest; public information and education directed at concepts of family planning and avoiding unintended pregnancies; and increased efforts to involve boys and young men in family planning. The committee realizes, however, that the problem of adolescent pregnancy will not be completely solved by increasing access to family planning services. Peer pressure toward early initiation of sexual activity is not balanced by societal incentives to delay childbearing. An improved educational system, increased opportunities for interesting employment for young women and men, and economic assistance for youth who seek advanced training and/or education will likely be essential components of a campaign to reduce pregnancy among adolescents. Summary Numerous opportunities exist before pregnancy to reduce the incidence of low birthweight, yet these are often overlooked in favor of interventions during pregnancy. In a fundamental sense, healthy- pregnancies begin before conception. The committee emphasizes, therefore, the importance of prepregnancy risk identif ication, counseling, and risk reduction; health education related to pregnancy outcome generally and to low birthweight In particular; and full availability of family planning services, especially for Cow income women and adolescents.

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130 References and Notes 8. Stein Z. Susser M, Saenger G. and Marolla F: Famine and Human Development: The Dutch Hunger Winter of 1944-1945. New York: Oxford University Press, 1975. 2. Fuhrmann R. Reiher H. Semmler K, Fischer F. Fischer M, and Glockner E: Prevention of congenital malformations in infants of insulin-dependent diabetic mothers. Diabetes Care 6:219-223, 1983. 3. Chamberlain G: The prepregnancy clinic. Br. Med. J. 281:29-3O, 1980. 4. Queenan JT: Prepping your patients for pregnancy. Contemp. Obstet. Gynecol. 21:11, 1983. 5. Alexander Burnett, M.D., Obstetrician-Gynecologist, Chevy Chase, Md. Personal communication. 6. Bakketeig LS, Hoffman HO, and Harley EE: The tendency to repeat gestational age and b~rthweight in successive births. Am. J. Obstet. Gynecol. 135:1086-1103, 1979. 7. Cefalo RC and Moos ME: Preconceptional health and fitness to prevent reproductive casualties. Unpublished paper. Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of North Carolina School of Medicine, Chapel Hill, 1984. Orr MT: Sex education and contraceptive education in U.S. public high schools. Family Plan. Perspect. 14:304-313, 1982. 9. Sonenstein FL and Pittman RJ: The availability of sex education in large city SChOO1 districts. Family Plan. Perspect. 16:19-25, 1984. 10. The Alan Guttmacher Institute: School sex education in policy and practice. Public Policy Issues in Brief 3:1-6, February 1983. 11. Select Panel for the Promotion of Child Bealth: Behavioral aspects of maternal and child health: Natural influences and educational intervention. Prepared by PD Mullen. In Better Health for Our Children: A National Strategy. Vol. IV, pp. 127-188. DHHS No. (PHS) 79-55071. Public Health Service. Washington, D.C.: U.S. Government Printing Office, 1981. 12. Morris NM, udry JR, and Chase CL: Shifting age-parity distribution of births and the decrease in infant mortality. Am. J. Public Health 65:359-362, 1975. 13. 14. 15. 16. - Grossman M and Jacobowitz S: Variations ~n infant mortal~ty rates among counties of the United States: The roles of public policies and programs. Demography 18:695-713, 1981. Thor ne MC and Green DW: The contribution of family planning programs to health: From correlations to causal inference. 1977 revision of paper presented at the Annual Meeting of the Population Association of America, Montreal, Canada, 1976. Dryfoos JG: Contraceptive use, pregnancy intentions and pregnancy outcomes among U.S . women. Family Plan. Perspect. 14:81-94, 1982. Zelnik M and Rantner JF: Contraceptive patterns and premarital Dreanancv among women aged 15-19 in 1976. 1978. Family Plan. Perspect. . _ ~ 10:135-142, 17. Forrest JD, Hermalin AI, and Henshaw SK: The impact of family planning clinic programs on adolescent pregnancy. Family Plan. Perspect. 13 :109-116, 1981.

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131 8 . National Center for Health Statistics : Interval between births: United States, 1970-1977. Prepared by E Spratley and S Taffel. Vital and Health Statistics, Series 21, No. 39. DHHS No. (PHS) 81-1917. Public Health Service. Washington, D.C.: U.S. Government Printing Office, August 1981. 19. Select Panel for the Promotion of Child Health: Better Health for Our Children: A National Strategy. Vo1. I. DHHS No. (PHS) 79-55071. Public Health Service. Washington, D.C.: U.S. Government Printing Office, 1981. 20. Kleinman JC, Machlin SR, Cooke MA, and Kessel SS: The relationship between delay in seeking prenatal care and the wantedness of the child. Paper presented at the Annual Meeting, American Public Health Association, Anaheim, Calif., November 11-15, 1984. 21. Rlerman LV and Jekel JF: Unwanted pregnancy. In Perinatal Epidemiology, edited by MB Bracken, pp. 283-300. University Press, 1984. New Yor k: Oxfor ~ Kreipe RE, Roghmann RJ, and McAnarney ER: Early adolescent childbear ing: A changing morbidity? J . Adolesc . Health Care 2: 127-131, 1981. 24 . 25. 26. 28. 23. Lanman JT, Kohl SG, and Bedell JH: Changes In pregnancy outcome after liberalization of the New York State abortion law. Am. J. Obstet. Gynecol. 118: 485-492, 1974 . Quick ~D: Liberalized abortion in Oregon: Effects on fertility, prematurity, fetal death and infant death. Am. J. Public Health 68:1003-1008, 1978. Rovinsky JJ: Impact of a permissive abortion statute on community health care . Obstet. Gynecol . 41: 781-788, 1973 . Torres A and Forrest JO: Family planning clinic services in the United States, 1981. Family Plan. Perspect. 15:272-278, 1983. 27. Henshaw SR and O'Reilly R: Characteristics of abortion patients in the United States, 1979 and 1980. Family Plan. Perspect. 15:5-16, 1983. Westoff OF, DeLung JS, Goldman N. and Forrest JO: Abortions preventable by contraceptive practice. Family Plan. Perspect. 13:218-223, 1981. 29. The Alan Guttmacher Institute: Ouestions and answers about Title . . . . _ . . _ . . X and family planning. Public Policy Issues in Br fief 4 :1-4, March 1984 . The Alan Guttmacher Institute: Eleven Million Teenagers: What Can Be Done About the Epidemic of Adolescent Pregnancies in the United States? New York, 1976. McCormick MO, Shapiro S. and Starfield OH: Higher isk young mothers: Infant mortality and morbidity in four areas in the Un' ted States, 1973-1978 . Am. J . Public Health 74 :18-23, 1984 . Chamie M, Eisman S. Forrest Jo, Orr Me, and Torres A: Factors affecting adolescents' use of family planning clinics. Family Plan. Perspect. 14 :126-139, 1982. Zabin LS and Clark SD Jr: Institutional factors affecting teenagers' choice and reasons for delay in attending a family planning clinic. Family Plan. Perspect. 15: 25-30, 1984 .