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Contraceptive Research and Development: Looking to the Future (1996)

Chapter: 3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods

« Previous: 2 The Need and Demand for New Contraceptive Methods
Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
×

2
The Need and Demand for New Contraceptive Methods

Issues of Terminology

In the context of family planning and contraception, the terms "need" and "unmet need" are applied, qualitatively and quantitatively, in several overlapping and intersecting ways, depending on the purposes of their application. They may incorporate the notions of "demand,'' "unmet demand," or "potential demand" or even be used interchangeably with those terms; and all terms are almost inevitably entangled with various conceptualizations of "preferences" and "intentions." The definition and computation of who "needs," "demands," "prefers," and "intends" what, and under which circumstances, have been debated for well over a decade. The debate is, however, far from an arid academic exercise: Its results have always been significant for the design, implementation, and evaluation of family planning programs. Because the terminology debate is vitally connected to the commodities, that is, the fertility regulation technologies that are essential to family planning, it has large and necessary implications for the pace and direction of contraceptive research and development, as well as for the involvement of industry in R&D processes.

Accordingly, this chapter begins with issues of terminology and its quantitative implications, as a basis for thinking about the personal and public health components of current needs for contraceptive technologies in the United States and worldwide. Some of these needs are general , in the sense that they are needs for contraception; others, addressed more fully in Chapter 5, are specific needs for new contraceptive technologies which have, in the eyes of this committee, clear implications for the market. "General needs" include the consequences of

Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
×

Figure 2-1

General needs for contraception, specific needs for new contraceptive methods, and the market created by these shared needs.

unintended pregnancy, notably abortion and maternal mortality, and the changing requirements of the reproductive life span. "Specific needs" include sexually transmitted reproductive tract infections; lack of involvement of males in contraception; and contraceptive failure and side effects. Figure 2-1 presents this breakdown in graphic form.

Market Demand

In economics, "demand" has both volitional and authoritative dimensions, since it comprises the notions of desire to purchase and possess, as well as the power to do so. In classical microeconomic theory, demand has an iterative relationship with supply, a relationship that is mediated by the market, which transmits information about prices, quantities, and elasticities in each.

However, application of traditional supply-and-demand concepts to understanding the role of demand in processes of technological innovation has not been very illuminating (Lotz 1993; Mowery and Rosenberg 1982). A more rewarding perspective is offered by marketing research, which distinguishes between "needs," "wants," and "demands'' in ways that are useful for thinking about development of new medical technologies in general and contraception in particular. In one analysis, a human need is defined as "a state of felt deprivation of

Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
×

some basic satisfaction," wants as "desires for specific satisfiers of these deeper needs," and demands as "wants for specific products that are backed up by an ability and willingness to buy them." The more explicitly needs are articulated as demands, the higher the likelihood that the "demander'' will be willing to pay for satisfaction of those needs (Kotler 1988).

The concept of market demand introduces the important notion of "signals," or expressions that come from a potential user—or third-party population—with both the willingness and ability to pay for satisfying needs and wants that are assumed to be in some way "unmet" (Lotz 1993; Nelson and Winger 1977). These may be (a) very specific signals about product specifications; (b) signals about a roughly described product; (c) signals about product class; (d) signals about demand for some kind of functions; or (e) no signals whatsoever, even if demands exist. The degree to which these can be determined will have a lot to do with the probabilities that investment will be attracted and that innovation will occur (Teubal et al. 1976). The sending and receiving of signals and the overall influence of demand factors on investment—in this case, investment in medical innovation—is not at all straightforward or linear; on the contrary, it is highly iterative (Gelijns and Pannenborg 1973; Lotz 1993; Mowery and Rosenberg 1982). It is also highly dependent on knowledge about the "owners" of the needs, that is, the "users," their preferences, and the expression of those preferences in patterns of adoption.

In this framework, the populations that are germane to conceptualizing the market for the outputs from contraceptive research and development are

  1. the population that
  • (a)  

    has been defined as having an unmet need for family planning, and

  • (b)  

    has evidenced a desire to actively use contraception in response to that need; and

  • the subset of that population (or some third party) which can—and will—pay for the satisfaction of those needs and desires.
  • Thus, the "market demand" population is always the smallest subpopulation in the set. If it cannot be identified somehow as substantial, there is no incentive for a potential product developer or seller to invest in this particular market. Therefore, from a commercial perspective it is crucial to determine what fraction of the "unmet need" population represents a true market opportunity.

  • Calculating the Unmet Need for Contraceptives

    Like "demand," "unmet need" is an elusive concept, changing according to how survey questions are posed, what assumptions are made, and the criteria used for exclusion and inclusion (Dixon-Mueller and Germain 1992). All these elements affect quantification of the ultimate size of the population defined as

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    needing contraceptive protection, as well as estimates of what is needed in the way of services and commodities. The definition of unmet need is surely crucial for computing the market for contraceptive technologies.

    Over the past 15 years, there have been numerous alternative calculations of the need and demand for contraceptives. The most generally accepted have been those authored by Westoff (e.g., Westoff and Ochoa 1991), which have been enormously useful in defining national family planning policies and prioritizing the need for international assistance. However, these approaches have been revisited recently from a women's health perspective and revised in a way that defines the base population more broadly (Dixon-Mueller and Germain 1992 and 1994; Guttmacher Institute 1995a; Wulf 1995) (see Table 2-1). The rationale for "casting a wider net" is that conventional definitions, which essentially restrict the unmet-need concept to married women1 and nonusers of contraception, respond neither to the contemporary realities of women's (or men's) lives, nor to the statistical realities concerning contraceptive utilization, effectiveness, and appropriateness.

    The expanded definition adds to the basic conventional definition the following population groups:

    • sexually active, unmarried women;
    • women with postpartum amenorrhea;
    • women who are using a less effective contraceptive method but who definitely want to avoid or postpone childbearing;
    • women who are using a more effective method but who are using it incorrectly, are dissatisfied, or should not be using it for health reasons;
    • women with unwanted pregnancies; and
    • women with related reproductive health problems (Dixon-Mueller and Germain 1994).

    Both the conventional and expanded definitions can be used to calculate need in national population subgroups by residence, age, and even subculture, and to compare countries in terms of magnitudes and characteristics of need and the ability of women in those countries to realize their reproductive wishes. Nonetheless, the effects of their different premises on calculation of unmet need can be strikingly large in the aggregate, ranging from an estimated 120 million (Ketting 1994; Robey et al. 1992) to 228 million women at risk of unplanned pregnancy even though they do not want to have a child (Guttmacher Institute 1995a).

    Reproductive Preferences

    Reproductive preferences have been a routine part of fertility and family planning surveys from their inception, as these surveys have sought to quantify

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    and measure fertility norms (desired or ideal number of children), reproductive intentions (intentions to postpone or terminate childbearing), spacing intentions (preferred length of the next birth interval), and wanted and unwanted births (intendedness).

    Reproductive preferences are also integral to defining unmet need. While preference data were for a long time viewed as the "soft" part of demographic surveys, recent methodological research has raised confidence in their predictive validity, although that is variable. For example, using the "ideal" or ''desired" number of children has been thought to lack any particularly predictive utility, because it reflects societal norms more than it truly reflects individual intentionality. However, though there may be some erosion in individual preferences in response to personal, family, or societal pressures (Freedman 1990), the percentage of women who state that they want no more children is a good short-term predictor of fertility rates (Westoff 1991). As such, it is a reasonable indicator for purposes of user-based market analysis, despite the inevitable divergence between the number of children women say they wanted or would want in the future and the number they actually have (the "KAP [knowledge, attitudes, and practices] gap").2

    Since there have been some dramatic changes in fertility levels worldwide during the past two decades, it is reasonable to assume that there has been some kind of fit between women's preferences and their actual behavior. The fact that the fit is imperfect does not invalidate the measure. At the same time, even the most meticulously shaped definition of either unmet need or unmet demand omits a number of qualitative variables that are crucial to conceptualizing the market for new contraceptive technologies. Discounting the force of various dimensions of local culture—for example, politics, gender roles, and the values assigned to fertility—and assuming that women everywhere will behave in the same ways given equivalent knowledge, resources, and options, is as risky for calculating a market as it is for implementing family planning programs.

    Third-Party and Public Health Perspectives

    Having defined a population with an unmet demand for contraception, it is then possible to address the question of what fraction of that population represents true market demand. As suggested at the beginning of this chapter, there are two very different subpopulations to be accounted for: Subpopulation 1, consisting of those able and willing to spend their own resources; and Subpopulation 2, consisting of those for whom some third party is prepared to pay. This latter, "third-party" category contains considerable variety: private insurance companies, managed care organizations, hybrid network arrangements, and government programs for the poor in the United States and other developed nations, as well as national family planning and public health sector programs in develop-

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-1 Comparison of Two Approaches to Calculating Unmet Need for Family Planning

     

    Westoff and Ochoa (1991)

    AGI (1995) Includes

     

    Population

    Include as Having an

    as Having an Unmet

    Assumptions Underlying

    Characteristics

    Unmet Need for Contraception:

    Need for Contraception:

    AGI Calculations

    Union status

    All women currently in union

    All women of reproductive age

    Many single women also have a need to avoid pregnancy

    Age

    Aged 15-49

    Aged 15-44

    Women aged 45-49 are probably infecund in any event

    Pregnancy

    All women who did not want most recent pregnancy and were not contracepting at time of that conception

    All women who do not want current pregnancy, whether or not contracepting at time of that conception

    Some women are unable to use any method effectively or are using a method with high failure rates

    Amenorrhea postpartum

    All women who did not want most recent pregnancy and were not contracepting at the time of that conception

    All women who do not want another child, soon or ever, and are not using an effective method of contraception

    All have a need even if, technically, they cannot conceive at the moment

    Use of postpartum abstinence

    Women using postpartum abstinence

     

    Although the abstinence may not be intended to prevent pregnancy, it nonetheless has assured contraceptive effect, so that women maintaining postpartum abstinence are not in need

    Method use

     

    Women using traditional methods of contraception (rhythm, withdrawal, etc.)

    Traditional methods can have high failure rates and thus do not offer effective protection from unintended pregnancy

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

     

    Excludes:

    Excludes:

     

    Fecundity

    All women married for at least 5 years, not contracepting, and who have not had a child during that time

    Only women who themselves say they cannot have a child; women who do not so indicate are defined as "in need"

    Unless women indicate that they have been infecund during this period, they might actually have conceived during a period assumed to be infecund and then had an abortion

    Note: "Includes" means that women with these characteristics are included in the pool of women considered to have an unmet need for contraception. "Excludes" means that women with these characteristics are not included in that pool, since either their need is viewed as satisfied or they are not considered at risk of conception.

    Sources: Alan Guttmacher Institute (AGI). Hopes and Realities: The Gap Between Women's Aspirations and Their Reproductive Experiences. New York: The Alan Guttmacher Institute. 1995. Westoff CF, LH Ochoa. Unmet Need and the Demand for Family Planning. DHS Comparative Studies, No. 5. Columbia, MD: Institute for Resource Development. 1991. Wulf D. The Unmet Demand for Family Planning. Unpublished paper. New York: Rockefeller Foundation, 1995.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    ing and industrializing countries, often at least partly subsidized by overseas development assistance.

    These subpopulations also have slightly different perspectives regarding the "value" or cost-effectiveness of contraception. Individuals, who do not as directly bear some of the broader social costs of increased population size that result from less-than-optimal levels of contraception, give primary emphasis to efficacy, side effects, out-of-pocket costs, and personal concerns such as convenience and autonomy. In contrast, third-party payers are more likely to be sensitive to the costs of unintended pregnancies, in terms of the cost and risks of abortion and the costs and risks of carrying unintended pregnancies to term.

    In the developing world, there is more heterogeneity in perspectives on family planning and contraception, depending on the history of a given country, its culture and religions, and where it is demographically, economically, and epidemiologically. Some countries, particularly those whose fertility rates remain high, must continue to worry about population growth rates, sizes, and densities. A growing number of other countries, further along in the demographic and epidemiologic transitions, must address both an "unfinished agenda" of high mortality, infectious disease, and malnutrition and a swelling agenda of noncommunicable and chronic diseases in adults and the elderly (Mosley et al. 1993). All countries, sooner or later, will find themselves obliged to somehow add to their priorities the new agenda, articulated at Cairo and ratified at Beijing, relating to the empowerment of women and their reproductive health and rights. The fact that these economies must take into account all these valid and pressing agendas and must do so with persistently constrained health sector resources means that they, like the established market economies and the formerly socialist economies of Europe, are also having to focus hard on issues of cost containment, cost-effectiveness, and cross-sectoral externalities and trade-offs in development investment (World Bank 1993). But here, too-and this is important-individuals have the same concerns and needs as do individuals in developed countries: they do not voluntarily choose to use contraception primarily because of national demographic or macroeconomic concerns.

    There is a third area where individual and societal health needs coincide because their nature is such that, left unsatisfied, they incur costs of some kind which can be quantified, albeit in different ways. The costs of contraception can then be compared to the costs of nonsatisfaction of these shared individual and public health needs so that, in some cases, it is possible to develop cost-benefit or cost-effectiveness ratios. At a minimum, it is possible (though not necessarily simple) to calculate the various costs of a given case of "nonsatisfaction" to whoever the payer is: the society at large, some third-party payer, or an individual. These shared unmet needs include unintended pregnancy, abortion, maternal mortality and morbidity, and sexually transmitted disease, needs which can be especially acute and especially costly in populations of particular vulnerability owing to such covariates as age, parity, ethnicity, or socioeconomic status.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    The societal costs of all of these are high and, in some instances, can only increase, either because the magnitude of the need itself increases, or because it will simply become more expensive to deal with, or both. Contraception offers very cost-effective and risk-reducing alternatives to unwanted pregnancies, whether those pregnancies are terminated by abortion or allowed to go to term, as well as to morbidity (Lee and Stewart 1995; Trussell et al. 1995). At present in the United States, a majority of third-party payers would seem to be missing a major investment by not offering a broad range of contraceptives as a cost-containment strategy that has potential economic payoff well in excess of many other forms of health care. We will argue in Chapter 5 that contraception that includes or is accompanied by protection against sexually transmitted diseases is even more cost-effective and surely risk-reducing. As more and more third-party payers assume long-term responsibility for covering large, stable populations over a long period of time for a broad range of health care services, it is reasonable to assume that they will look to those savings that can be derived from prevention and, therefore, see the economic value and consequent logic of substantially increasing their investment in contraceptive and reproductive health services as a major cost-containment tool. This will not be an overnight process. Ongoing restructuring of the managed care industry and the current mobility of subscribers shopping for the best care at the best price will, for a while, affect the potential for a given HMO to realize a payback from investment in prevention. At the same time, the payback from pregnancy prevention, with its rapid "turnaround" and transparent causal attribution, can be realized much faster than, for instance, the payback from nutrition education and prevention of high-cost chronic diseases.

    A Life Span Perspective

    There is a growing constituency in the public health community for a more inclusive and integrative model of individual and family health and well-being, and use of the phrases "life cycle" and "life span" to define a perspective have acquired a certain currency, particularly in connection with women's health and well-being. The basic premise of this perspective is that human health and illness are not a haphazard affair, but express the accumulation of conditions that begin early in life, in some respects before birth. A second premise is that the factors that favor good health and precipitate ill health are not purely genetic or biological but can be social, economic, cultural, and psychological, and can work together or against one another across the span of an individual's life in ways that we are only beginning to understand. The third premise is that no reasonable public health strategy can ignore these dynamics and what constitutes a continuity of risk over an entire lifetime (Institute of Medicine [IOM] 1996; Tinker et al. 1994; UNFPA 1994; World Bank 1994). The importance of the life span concept to this report is straightforward enough: At different points across their life

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    spans, women have different reproductive intentions, different pressures on their lives, different needs for contraception, and different overall reproductive health requirements. Contraceptive research and development has to take all of these life span dimensions into account since, to a large extent, they shape the structure of demand.

    In developed countries, the portion of the female life span that can be described as the "potential reproductive years," that is, the years between menarche and menopause, constitutes about half of a woman's total life span; in developing countries, where life expectancies are generally shorter, that portion can be well over half. This means that a typical woman in the United States is at biological risk of pregnancy for approximately 36 years (Hatcher et al. 1994). Fourteen percent of those potential reproductive years (or years at biological risk of pregnancy) is spent in Stage 1, the years between menarche and first intercourse, and 19 percent in Stage 2, the years between first intercourse and marriage; during these two stages, the large majority of women will be trying to avert or postpone pregnancy. Stage 3 comprises the years between marriage and first birth, or 5 percent of the years at risk, during some part of which some women will be averting or postponing pregnancy. Stage 4, the years between first birth and attainment of desired family size, represents 11 percent of the potential reproductive years, during which the emphasis for most women is on spacing births. The years that follow, that is, the years between attainment of desired family size to menopause (Stage 5) occupy 51 percent of the whole span of potential reproductive life. This span of years consists of two periods, the boundary between which is typically blurred except for women who are surgically sterile. The first is the period between the age of intending no more children and presumed3 sterility, during which many women will want to avert pregnancy; the second comprises the years from presumed sterility to menopause, when there is no concern for contraception. Nevertheless, during Stage 5 and into the postmenopausal period (Stage 6), many women will still require protection from sexually transmitted infection, as is increasingly the case for many women throughout their reproductive years (Forrest 1993).

    For women who want a certain number of children, these proportions change somewhat to account for the years spent in pregnancy, postamenorrheic abstinence or infecundity, or sexual inactivity. The hypothetical woman who is sexually active between ages 20 and 45 and wants two children will need protection from pregnancy for approximately 20 years, that is, 82 percent of her 25-year reproductive life. The woman who wants four children will need protection for about 16 years, or 64 percent of her reproductive life. Even the woman who wants six children will need nearly 12 years of protection, or 46 percent of her reproductive life (see Table 2-2). For women who begin childbearing in their teenage years, these estimates are, of course, conservative. The general rule is that, for all women, everywhere, the younger they are when they begin their reproductive lives, the older they are at menopause; the fewer children they want,

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-2 Proportions of Female Reproductive Life During Which Protection from Pregnancy Is Needed

    Number of Children Wanted by Hypothetical Woman

    Number of Months Wanting Pregnancy

    Number of Months Being Pregnant

    Number of Months Postpartum Protection

    Number of Months Not Wanting Pregnancy

    Number of Years Not Wanting Pregnancy

    % of Total Reproductive Life

    2

    24

    18

    12

    246

    20.5

    82.0

    4

    48

    36

    24

    192

    16

    64.0

    6

    72

    54

    36

    138

    11.5

    46.0

    Note: Reproductive life span is hypothesized to be 300 months, or 25 years, from age 20 to age 45.

    Source: Alan Guttmacher Institute. Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences. New York: The Alan Guttmacher Institute. 1995.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    the longer they must spend in need of some kind of contraception (Guttmacher Institute 1995a).

    The stages in the potential reproductive years can be further characterized according to the ways they differ from one another biologically, socially, and psychologically, as well as in the balance required among prevention of pregnancy, protection from disease, and preservation of fertility (Fathalla 1992; Forrest 1993; Fortney 1989; King and Smith 1994). Obviously, transition from stage to stage is not uniform among women or among societies. Women do not transit at the same age or in the same order, and some women in some situations may even skip a stage or advance into a next stage in ways that can be biologically or socially worrisome. Unduly early or unduly late pregnancies are prime examples: The fact that many women in the world have their first baby while they are still adolescents can have high costs: Even when prepregnancy disadvantages are taken into account, early childbearing appears to have a causal and adverse effect on the health and social and economic well-being of children and, in varying measure, on their mothers (IOM 1995; Kubicka et al. 1995).4

    Table 2-3 examines each stage of female reproductive life in terms of a few key biological, social, and psychological variables; fertility goals, sexual behavior, and contraceptive use; and the qualities of contraception that are particularly necessary at certain times. The table includes the postmenopausal years even though this period lies beyond what are biomedically defined as the reproductive years, since many women continue to be sexually active; because of menopause-associated physiological changes (e.g., structural changes in vaginal tissues), those women remain vulnerable to sexually transmitted infections. This means that continued protection against those infections may be required later in the course of women's lives than is usually thought to be the case, a dimension that is appropriate to thinking about prospects for new reproductive technologies.

    The principal message that emerges from this scrutiny of the texture of the female reproductive life span is that, at various points in their lives, women everywhere have different reproductive intentions and, consequently, different needs for family planning and the maintenance of their reproductive health. This means that, first of all, contraceptive services need to offer a full range of methods that are responsive to these changing requirements. Second, viewing contraceptive technology from the perspective of the overall reproductive life span makes it clear that there are periods of that span that are not now served well or appropriately by the current array of methods; most strikingly, there are considerable limitations in what is available for very young women and for women later in life who wish to preserve their fertility but who cannot use the long-term, high-effectiveness methods that are currently on the market.

    Preferences and Intentions

    Over the past four decades in the United States, as part of the National

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    Survey of Family Growth (NSFG) and its predecessors,5 a series of questions has been regularly asked of women about the timing and intentionality of their pregnancies. Efforts to capture responses of this type are difficult at best, and many vulnerabilities and complexities intrude. The fragility of human recall, changes in circumstance, ambivalence, differences of meaning, shifts in intensity of feeling, all come into play. However, the NSFG has developed very specific terminology and definitions to measure "unintended pregnancy," using the following definitions of "intended" and "unintended'':

    • intended at conception: wanted at the time, or sooner, irrespective of whether or not contraception was being used; or
    • unintended at conception: if a pregnancy had not been wanted at the time conception occurred, irrespective of whether or not contraception was being used.

    Among unintended pregnancies, a further distinction is made between mistimed and unwanted:

    • mistimed conceptions are those that were wanted by the woman at some time, but which occurred sooner than they were wanted; and
    • unwanted conceptions are those that occurred when the woman did not want to have any more pregnancies at all (IOM 1995).

    These definitions have been applied in a large number of national and international surveys in ways that are similar enough to be considered comparable. As suggested in the preceding section, by these definitions almost all women—and this is true worldwide—are at risk6 for unintended pregnancy throughout most of their reproductive years (Forrest 1994). The next sub-sections present the ways in which these various elements of unintended pregnancies are expressed, internationally and in the United States.

    Unintended Pregnancy Worldwide

    Everywhere in the world, there is often a gap between the number of children women say they want and the number they actually have. Substantial percentages of women report everywhere that they have had all the children they want or that they do not want another pregnancy for at least two years. Many also report that their most recent birth was unwanted or mistimed.7 And, for many of the world's women, the alternative to carrying an unintended birth to term, whether that birth was mistimed or unwanted, was abortion (see Figure 2-2).

    The ranges of each of those categories of intention, preference, and action differ from region to region and from country to country, as one would expect (Table 2-4 and Table 2-5). The highest regional percentage of wanted births, 76

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-3 Life Span Factors in Women's Reproductive Lives

     

    Stage 1

    Stage 2

     

    Menarche-Intercourse

    Intercourse-Marriage

    Biologic variables

    Menarche

    First intercourse

    High reproductive capacity

    High risk of exposure to STDs

    High risk of unintended pregnancy

    High maternal/child mortality and morbidity from too-early pregnancy

    Social variables

    Politically most contentious stage

    Restricted provision of family planning services

    Constrained access to information about sexuality and contraception

    Politically contentious

    Laws governing age at marriage

    Restricted provision of family planning services

    Psychological variables

    Limited future orientation/ ability to judge risks/consequences/defer gratification

    Heightened sense of unique invulnerability

    Need to establish adult identity/peer intimacy

    Constrained ability to negotiate use of coitus-related methods

    Ambivalence

    Constrained ability to negotiate use of coitusrelated methods

    Ambivalence

    Fertility goals:

     

     

    Childbearing

    Future fertility

    Postpone

    Preserve

    Postpone

    Preserve (high need)

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

     

     

    Stage 4

     

     

     

    Stage 3

    1st Birth-Attainment of

    Stage 5

    Stage 6

     

    Marriage-1st Birth

    Desired Family Size

    Menopause

    Postmenopause

    Biologic variables

    Marriage

    High reproductive capacity

    Possible fetal

    wastage/ectopic

    pregnancy/infertility

    Intend no more children

    High reproductive capacity

    Sterility/infertility

     

     

     

     

     

    Increased incidence and severity of many gynecologic problems

    Social variables

     

    Parity requirements for sterilization

    Irrelevant

     

    Psychological variables

    Greater intellectual/ emotional maturity/ ability to judge consequences

     

    Heightened maturity

     

    Fertility goals:

     

     

     

     

    Childbearing

    Postpone

    Space

    Stop

     

    Future fertility

    Preserve (high need)

    Preserve (diminishing need)

    Irrelevant

     

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

     

    Stage 1

    Stage 2

     

    Menarche-Intercourse

    Intercourse-Marriage

    Sexual behavior:

     

     

    No. of partners

    Variable

    Variable to higher

    Frequency of intercourse

    Variable

    Variable to higher

    Coital predictability

    Low

    Moderate to high

    Contraceptive use

    None

    Erratic use/high discontinuation

    Most common methods

    Pill

    Pill

    Next most common

    Condom

    Condom

    Importance of method characteristics:

     

     

    Conception prevention

    High

    Moderate

    Reversibility

    High

    High

    Not coitus-linked

    High

    Low

    STD prevention

    High

    Moderate (if monogamous)

    Safety during breastfeeding

    High

    High

    Note: STDs = sexually transmitted diseases.

    Sources: Modified from Forrest JD, Timing of reproductive stages, American Journal of Obstetrics and Gynecology 82:110, 1993, and Hatcher RA, J Trussell, F Stewart, et al. Contraceptive

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

     

     

    Stage 4

     

     

     

    Stage 3

    1st Birth-Attainment of

    Stage 5

    Stage 6

     

    Marriage-1st Birth

    Desired Family Size

    Menopause

    Postmenopause

    Sexual behavior:

     

     

     

     

    No. of partners

    Variable Challenge to discern infidelity/self-protect against STDs

    Variable

    Variable

    Variable

    Frequency of intercourse

    Variable

    Variable

    Variable

    Variable

    Coital predictability

    High

    High

    High

    High

    Contraceptive use

     

     

     

     

    Most common methods

    Sterilization

    Sterilization

    Irrelevant

     

    Next most common

    Pill, condom

     

     

     

    Importance of method characteristics:

     

     

     

     

    Conception prevention

    High

    Irrelevant

    Irrelevant

     

    Reversibility

    Low

    Low to irrelevant

    Irrelevant

     

    Not coitus-linked

    Moderate

    Irrelevant

    Irrelevant

     

    STD prevention

    Low (if monogamous)

    Low (if monogamous)

    Low (if monogamous)

    Low (if monogamous)

    Safety during breastfeeding

    Moderate

    Irrelevant

    Irrelevant

     

    Technology, 16th revised ed., New York, Irvington Publishers, 1994. We have added Stage 6, the postmenopausal period, since many women remain sexually active despite termination of fertility, and may require protection from sexually transmitted infections.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    Figure 2-2

    Percentage of births unintended, selected countries, 1985-1992. Source: Alan Guttmacher Institute. Women, Families, and the Future: Women and Reproductive Health (Regional Fact Sheet). New York: The Alan Guttmacher Institute. 1994.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-4 Distribution of Pregnancies by Outcome, Selected Developing Regions and Developed Countries (various dates, in percentages and millions of pregnancies)

     

     

    Wanted

    Mistimed

    Unwanted

    Abortion

    Region

    Number of Pregnanciesa

    %

    No.a

    %

    No.a

    %

    No.a

    %

    No.a

    Sub-Saharan Africa (1994)

    28.9

    76

    22.0

    10

    2.9

    3

    0.9

    11

    3.2

    North Africa and Middle East (1994)

    11.6

    58

    6.7

    12

    1.4

    18

    2.1

    12

    1.4

    South and Southeast Asia (1994)

    65.4

    63

    41.2

    10

    6.5

    9

    5.9

    18

    11.8

    Latin America (1994)

    16.4

    38

    6.2

    15

    2.5

    19

    3.1

    28

    4.6

    China (1990)

    40.4

    47

    19

    13

    5.3

    10

    4.0

    30

    12.1

    Japan (1992)

    1.9

    36

    0.68

    36

    0.68

    3

    0.06

    25

    0.47

    France (1991)

    1.1

    66

    0.73

    12

    0.14

    3

    0.03

    19

    0.21

    United States (1988)

    6.5

    43

    2.8

    19

    1.2

    9

    0.59

    29

    1.9

    a All numbers are in millions.

    Sources: This table was derived from a graphic presentation in: Alan Guttmacher Institute, Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences, p. 25, New York, Alan Guttmacher Institute, 1995. That graphic was, in turn, constructed from the following sources:

    For the developing regions of the world, the number of abortions and live births: Alan Guttmacher Institute, Women, Families and the Future, New York, 1995.

    For China, the number of abortions: Henshaw SK, Induced abortion: A world review, Family Planning Perspectives 22:76-89, 1990; the number of live births: United Nations, World Population Prospects: The 1994 Revision, New York, 1995.

    For France, the number of abortions and live births: Council of Europe, Recent Demographic Developments in Europe, 1993.

    For Japan, the number of abortions: Ministry of Health and Welfare, The Report on the Statistics Relating to Eugenics Protection, Tokyo, 1993; the number of live births: Vital Statistics of Japan 1992, Tokyo, 1994.

    For the United States, the number of abortions: Henshaw SK, J Van Vort, Abortion services in the United States, 1987 and 1988, Family Planning Perspectives 22:102-109, 1990; the number of live births: National Center for Health Statistics, Monthly Vital Statistics Report, Vol. 38, No. 6, 1989.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-5 Planning Status, Last Birth, and Preferences for Next Birth (selected countries, various survey years)

     

    Average Number of Children

    % Whose Last Birth Was Unplanned

    % Who Want to Stop or Postpone

    Country and Survey Year

    Wanted

    Havea

    "GAP"

    Mistimedb

    Unwantedc

    TOTAL

    Stopd

    Postponee

    TOTAL

    Cameroon, 1991

    6.7

    5.5

    -

    17

    5

    22

    45

    14

    59

    Nigeria, 1990

    5.9

    6.2

    +

    9

    3

    12

    53

    9

    62

    Pakistan, 1990-1991

    5.3

    5.9

    +

    8

    16

    24

    21

    40

    61

    Jordan, 1990

    4.9

    5.4

    +

    12

    26

    38

    28

    53

    81

    Guatemala, 1987

    4.2

    5.1

    +

    16

    13

    29

    40

    47

    87

    Kenya, 1993

    3.8

    6.0

    ++

    36

    20

    56

    33

    52

    85

    Egypt, 1992

    3.5

    3.7

    +

    9

    33

    42

    19

    67

    86

    Indonesia, 1991

    3.4

    2.8

    -

    16

    8

    24

    32

    54

    86

    Mexico, 1987

    3.2

    3.0

    -

    24

    27

    51

    18

    62

    80

    Philippines, 1992

    3.2

    3.8

    +

    26

    21

    47

    25

    63

    88

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

     

    Average Number of Children

    % Whose Last Birth Was Unplanned

    % Who Want to Stop or Postpone

    Country and Survey Year

    Wanted

    Havea

    "GAP"

    Mistimedb

    Unwantedc

    TOTAL

    Stopd

    Postponee

    TOTAL

    China, 1987-88

    2.8

    2.0

    -

    u

    u

    u

    17

    64

    81

    Thailand, 1987

    2.8

    2.1

    -

    18

    15

    33

    23

    66

    89

    Colombia, 1990

    2.6

    2.6

    =

    17

    21

    38

    20

    64

    84

    Japan, 1992

    2.6

    1.5

    -

    48

    4

    52

    7

    82

    89

    United States, 1988

    2.6

    2.1

    -

    26

    13

    39

    23

    64

    87

    France, 1994

    2.3

    1.7

    -

    15

    4

    19

    u

    u

    u

    Notes: u = Data unavailable; + = have more children than wanted; - = have fewer children than wanted; = = have number of children wanted.

    a United Nations estimate of total fertility rate.

    b Percentage of women 15-49 who had a child in the previous five years and whose last birth was not planned at that time.

    c Percentage of women 15-49 who had a child in the previous five years and whose last birth was not planned at any time.

    d Percentage of women 15-49 who want no more children.

    e Percentage of women 15-49 who want to delay the next birth.

    Source: Derived from Appendix Table 5 (Columns 1 and 5, 18 and 19, and 20 and 21), Alan Guttmacher Institute, Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experience, New York, The Alan Guttmacher Institute, 1995.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    percent, was reported by Sub-Saharan Africa, the next highest by South and Southeast Asia with 63 percent, followed by North Africa and the Middle East with 58 percent, and a low 28 percent of wanted births in Latin America. Although these are huge aggregations, it is worth noting that in Sub-Saharan Africa, where fertility norms are high, about one-fourth of most recent births were nonetheless unwanted. In the North Africa-Middle East region, close to half of recent births were unwanted, with most of that percentage deriving from unwanted rather than mistimed births. The highest regional abortion rates were in South and Southeast Asia, where 18 percent of all recent births were so terminated.

    There is inevitably variation among countries in almost all respects. First, there is gap between the family size women say they want and the family size they actually have: the "KAP gap." In some countries, for example, Colombia, Egypt, and Nigeria, women are close to having the total number of children they want; in fact, in Colombia, women say they are having exactly the number they want. (At the same time, 38 percent of Colombian women reported that their latest birth had been unintended, with intentionality divided almost equally between unwanted and mistimed births.) In contrast, in Guatemala, Jordan, Kenya, Pakistan, and the Philippines, the gap between the total number of children women want and the number they actually have was large. Not surprisingly, in countries where national policies discourage more than two children per family, notably China and Indonesia, some women would like more children than they actually have. However, the same was true in countries where there are no constraining policies—France, Japan, Mexico, Thailand, and the United States (Guttmacher Institute 1995a).

    The structure of unintendedness of the most recent birth varies internally according to the percentage of mistimed as opposed to unwanted pregnancies. The highest rates of overall unintendedness were reported by Japan, Kenya, Mexico, the Philippines, and Egypt, where close to half of latest births were unintended; Colombia, Jordan, Thailand, and the United States were close behind, with at least one-third of all births unintended. Within this structure, however, ranges differed. Rates of unwanted pregnancies ranged from 48 percent in Japan to 8 and 9 percent in Egypt, Nigeria, and Pakistan. The range for mistimed pregnancies was narrower, from 33 percent in Egypt to 3 and 4 percent in Nigeria, France, and the United States. Of the countries and regions for whom percentages of births ending in abortion were calculated, the highest rates were reported in China (30 percent), the United States (29 percent), Latin America (28 percent), Japan (25 percent), and France (19 percent); the lowest rates were in Sub-Saharan Africa (11 percent) (Guttmacher Institute 1995a).

    In sum, the large majority of women in virtually every country surveyed have indicated that they somehow wish to control future childbearing, either by not having another pregnancy (stopping) or postponing the next pregnancy for at least two years (spacing). The proportion of women actively wanting to become pregnant was very low—less than one in five—in developing and most devel-

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    oped countries. In the same sample analyzed in Table 2-4, the lowest percentages of women who want to either stop childbearing altogether or postpone it were in Sub-Saharan Africa yet, even there, these percentages were two-thirds of all women surveyed. Everywhere else, the percentages of women who wanted to control the occurrence or timing of their next pregnancy ran around 80 to 90 percent. Nevertheless, even in a number of countries where unintendedness rates were high (France, Japan, Thailand, and the United States, for example), the average woman nonetheless indicated that she would—overall—like slightly more children than she actually had. This suggests that attitudes toward family size are often ambivalent and highly sensitive to circumstance (Guttmacher Institute 1995a), so that timing of births and the ability to determine their spacing are crucial. Another message from these figures is related to the global nature of unintendedness. The Guttmacher Institute analysis notes: ''If these proportions are an indication of the success with which women plan their pregnancies, many women in the developed world appear to be doing no better than women in developing regions" (Guttmacher Institute 1995a).

    Unintended Pregnancy in the United States

    Of all pregnancies in the United States in 1987 (5.4 million), 57 percent were unintended at the time of conception. This figure includes pregnancies that were aborted, as well as both mistimed and unwanted pregnancies that led to live births (IOM 1995) (Table 2-6). In other words, of the estimated pregnancies in that year, less than half—43 percent, to be exact—were actually intended at conception and resulted in live births. The breakdown of unintended pregnancies shows that, while the majority of births from unintended pregnancies were from mistimed rather than unwanted pregnancies, half of all unintended pregnancies ended in abortion in that year. Whether the pregnancy was mistimed or unwanted does not affect the proportion of pregnancies ending in abortion: 51 percent of mistimed pregnancies and 50 percent of unwanted pregnancies end in abortion (Forrest 1994).

    Furthermore, the trend toward increase in unintendedness seems to be worsening. During the 1970s and early 1980s in the United States, a decreasing proportion of births were unintended at the time of conception. Between 1982 and 1988, this trend reversed and there was an overall increase in the proportion of unintended pregnancies among both unmarried and married women, and particularly among poor women (IOM 1995; Williams and Pratt 1990).

    Stratified analysis of these data upsets a number of preconceptions. First of all, women of all socioeconomic, marital-status, and age groups contribute to the pool of unintended pregnancies; adults as well as teenagers are having difficulty planning and preventing pregnancy. Second, although marital status, which is highly correlated with age, is also strongly related to whether a pregnancy is unintended, 4 out of 10 pregnancies among currently married women were either

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-6 Estimated Proportions of Pregnancies (excluding miscarriages) by Outcome and Intention, Percentage of Pregnancies Unintended, and Percentage of Unintended Pregnancies Ending in Abortion, United States, 1987, by Marital Status, Age at Outcome, and Poverty Status at Interview

    All Pregnancies (miscarriages excluded)

    Demographic Characteristics

    Total Pregnancies

    Intended Pregnancies Ending in Births

    Unintended Pregnancies Ending in Births

    Abortions

    Percentage of Pregnancies Unintended

    Percentage of Unintended Pregnancies Ending in Abortion

    Total

    100.1

    42.8

    28.4

    28.9

    57.3

    50.4

    Marital status

     

     

     

     

     

     

    Currently married

    100.0

    59.9

    29.7

    10.4

    40.1

    25.9

    Formerly married

    100.0

    31.5

    32.4

    36.1

    68.5

    52.7

    Never married

    100.0

    11.8

    22.0

    66.2

    88.2

    75.1

    Age

     

     

     

     

     

     

    15-19

    100.0

    18.3

    40.0

    41.7

    81.7

    51.0

    20-24

    100.0

    39.4

    29.7

    30.9

    60.6

    51.0

    25-29

    100.0

    54.8

    23.8

    21.4

    45.2

    47.3

    30-34

    100.0

    57.9

    21.0

    21.1

    42.1

    50.1

    35-39

    100.0

    44.1

    25.1

    39.7

    55.9

    55.1

    40-44

    100.0

    23.1

    31.3

    45.6

    76.9

    59.3

    Poverty Status

     

     

     

     

     

     

    <100%

    100.0

    24.6

    35.6

    39.8

    75.4

    52.8

    100-199%

    100.0

    36.0

    26.8

    37.2

    64.0

    58.1

    >200%

    100.0

    55.0

    25.7

    19.3

    45.0

    42.9

     

    Source: Institute of Medicine, The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families, S Brown, L Eisenberg, eds., Washington, DC: National Academy Press, 1995, based on: Forrest JD, Epidemiology of unintended pregnancy and contraceptive use, American Journal of Obstetrics and Gynecology 170:1485-1488, 1994.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    mistimed or unwanted. Third, the high rate of unintendedness in the United States is not explained by a higher incidence of abortion among minority women; it is simply that the total U.S. pregnancy rate, the total rate of unintended pregnancy, and the U.S. abortion rate are all higher than those rates in other Western nations, among all U.S. women (IOM 1995; Henshaw and Van Vort 1994). Fourth, although in 1987 82 percent of pregnancies in teenagers aged 15-19 were described as having been unintended, the same was true of 61 percent of pregnancies in women aged 20-24, 56 percent of pregnancies in women aged 35-39, and 77 percent of pregnancies in women over age 40; even among women aged 2534, between 42 and 45 percent of all pregnancies were described as unintended (IOM 1995). Fifth, while unmarried status is the most important factor in determining whether an unintended pregnancy will end in abortion, it is still the case that 1 in 4 unintended conceptions is aborted by currently married women. Sixth, while adolescents as a group do have the highest rate of unintended pregnancies—82 percent of all adolescent pregnancies are unintended—the proportion of unintended pregnancies among adolescents that end in abortion is not substantially different from other age groups and actually lower than in the older age groups (Forrest 1994).

    The Consequences of Unintended Pregnancy

    The consequences of unintended pregnancy are of various kinds—biological, social, economic, and emotional—and will also vary among regions, countries, and individuals. In addition, they will vary in their gravity from setting to setting, yet there is little evidence that unintended pregnancy is ever a truly trivial event. This section focuses on abortion and maternal mortality and morbidity as the principal biological consequences of unintended pregnancy. It also addresses the matter of the sexually transmitted diseases as a correlate of sexual activity that, more and more, must be taken into account in thinking about women's reproductive health in general and contraception in particular.

    Abortion

    Everywhere in the world, unintendedness in pregnancy is the antecedent of virtually all induced abortions (Chen 1995). The reasons for which women everywhere seek abortion reside in three fundamental causes: nonuse of contraception; contraceptive misuse or method failure; and lack of postovulatory or postcoital methods that a woman can use if she has been exposed to unprotected sex, in order to obviate the need to confront the dilemmas of abortion.

    The 40 million to 60 million abortions that take place worldwide each year represent 20-30 percent of all the world's pregnancies, or from 30 to 45 abortions per 1,000 women of reproductive age annually (WHO 1991).8 From 26 million to 31 million of these are legal; the remainder—somewhere around 20 million—

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    are nonlegal and mostly definable as "unsafe." This means that there is 1 unsafe abortion to every 10 of the world's pregnancies, or a ratio of one unsafe abortion to every seven births (WHO 1994). Of the total number of unsafe abortions, 17.6 million (88 percent) take place in the less developed countries, although there are significant variations among and within regions in terms of incidence of abortion and related mortality (WHO 1994) (see Table 2-7).

    Important to note is that, owing to the lack of appropriate contraceptives and counseling services, abortion was, and remains, the principal means of fertility regulation in the countries of central and eastern Europe (CCEE) and the newly independent states of the former USSR (NIS), sometimes equaling the number of live births and even exceeding it by two or three times. As a possible consequence of the economic crisis in which these countries find themselves, women fear that bringing up children is simply not affordable. At the same time, these governments are concerned about rapid decline of fertility rates to levels under replacement (Brandrup-Lukanow 1995).

    First-trimester abortion, performed with appropriate sterile technique by trained personnel, is a very safe surgical procedure and rates of complications have been decreasing in the United States (IOM 1995). However, unsafe abortions are characteristically performed by the woman herself, by nonmedical individuals, or by health workers in unhygienic conditions, and most occur where abortion is either illegal or, if it is legal, where service access and quality are limited (WHO 1994).

    In developing countries, the risk of death following complications of unsafe abortion procedures may be between 100 and 500 times higher than the risk of an abortion performed professionally under safe conditions (WHO 1994). The number of deaths worldwide each year that result from an abortion complication is estimated to be at least 70,000,9 but the margin of error in such statistics is so large that these numbers could be as low as 50,000 or as high as 100,000. Risk of death due to unsafe abortion is at least 15 times higher in developing countries than it is in developed countries and, in some regions, may be as much as 40 to 50 times higher. Looked at a bit differently, mortality from unsafe abortion in developing countries is around 55 per 100,000 live births; in developed countries, that figure is 4 per 100,000 (WHO 1994) (see Table 2-7). Not surprisingly, the complications of unsafe abortions are a leading cause of maternal deaths, over 98 percent of which occur in the developing world, where they account for around 13 percent (1 in 8) of all pregnancy-related deaths (WHO 1994). Urban rates in developing countries may be much higher: One well-designed study in the early 1980s in Addis Ababa, Ethiopia, found that 54 percent of maternal deaths in that city were due to illegal abortion (Kwast et al. 1986). Nonetheless, limitations in data-collection systems make it highly likely that rural abortion rates are underestimated.

    While the evidence is patchy and always fragile, there does appear to have been some overall decline in mortality from unsafe abortion. This may be due to

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-7 Global and Regional Estimates of Incidence of, and Mortality from, Unsafe Abortions

    Region

    Number of Unsafe Abortions (thousands)a

    Unsafe Abortions per 1,000 Women Aged 15-49

    Number of Deaths from Unsafe Abortionsa

    Mortality from Unsafe Abortions per 100,000 Live Births

    Maternal Deaths

    World Total

    20,000

    15

    70,000

    49

    13

    More Developed countriesb

    2,340

    8

    600

    4

    14

    Less Developed countries

    17,620

    17

    69,000

    55

    13

    Africa

    3,740

    26

    23,000

    83

    13

    Eastern Africa

    1,340

    31

    10,000

    101

    15

    Middle Africa

    180

    12

    2,000

    77

    11

    Northern Africa

    510

    16

    1,000

    23

    7

    Southern Africa

    230

    22

    500

    36

    13

    Western Africa

    1,480

    34

    10,000

    104

    14

    Asia

    9,230

    12

    40,000

    47

    12

    Eastern Asiac

     

     

     

     

     

    Southeastern Asia

    2,850

    25

    5,000

    43

    13

    Southern Asia

    6,000

    21

    33,000

    81

    14

    Western Asia

    380

    13

    1,000

    22

    8

    Europe

    260

    2

    100

    2

    10

    Eastern Europe

    110

    5

    <100

    4

    13

    Northern Europec

     

     

     

     

     

    Southern Europe

    150

    4

    <100

    2

    16

    Western Europec

     

     

     

     

     

    Latin America

    4,620

    41

    6,000

    48

    24

    Caribbean

    170

    19

    400

    50

    19

    Central America

    890

    31

    800

    23

    14

    South America

    3,560

    47

    5,000

    58

    26

    Northern Americac

     

     

     

     

     

    Oceania

    20

    17

    <100

    29

    5

    USSR (former)

    2,080

    30

    500

    10

    23

    Note: Figures may not add to totals owing to rounding.

    a Based on 1990 U.N. projections of births.

    b Japan, Australia, and New Zealand have been excluded from the regional estimates but are included in the total for developed countries.

    c For regions where the incidence is negligible, no estimates have been made.

    Source: World Health Organization. Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion, 2nd ed. Geneva: Division of Family Health. 1994.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-8 Mortality Risks Associated with Pregnancy and Selected Health Procedures

     

    Deaths per 100,000 Cases

     

    Procedure

    United States

    Developing Countriesa

    Legal abortion

    1

    4-6

    Female sterilization

    4

    10-100

    Delivery of live birth

    14

    250-800

    Cesarean section

    41

    160-220

    Illegal abortionb

    50

    100-1,000

    Hysterectomy

    160

    300-400

    a Estimated.

    b Performed by untrained practitioners or outside medical facilities.

    Source: Population Crisis Committee, World Abortion Trends, Briefing Paper No. 9, September 1982. Cited in: World Health Organization. Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion, 2nd ed. Geneva: Division of Family Health. 1994.

    changes in abortion laws and increased access to safe medical abortions and menstrual regulation; increased fertility regulation through contraception; and increased provider skills both within and outside formal health systems. However, this overall picture of decline masks an increase among certain groups in all parts of the world, notably unmarried adolescents in urban areas, where they may represent the majority of all abortion seekers. At the same time, as we will see below in the case of the United States, the general, popular image of the woman who seeks abortion does not accord with statistical reality. In the developing world, many women who seek abortions are married or live in stable unions, already have several children, may be using abortion to limit family size or space births, or may be resorting to abortion as a consequence of contraceptive failure or lack of access to modern contraception (WHO 1994).

    In addition to the hemorrhage so often associated with induced abortion, there are other primary and secondary complications which, if they do not produce fatality, may well produce serious and chronic disability. Infections may spread throughout the reproductive tract and produce acute pelvic inflammatory disease (PID), with tubal damage, secondary infertility, predisposition to ectopic pregnancy, chronic pain, and, in severe cases, formation of abdominopelvic abscess requiring emergency surgery and occasionally resulting in death (Meheus 1992). The procedure itself may cause mechanical damage to vagina, uterus, or adjoining structures; cervical lacerations may be responsible for subsequent miscarriage or premature births; and, where the procedure involves introduction of chemicals into the vagina, resulting tissue destruction may also contribute to

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    infection. There may be additional sequelae in the form of negative effects on subsequent pregnancy outcomes, notably, low birth weight, midtrimester spontaneous abortion, and premature delivery.

    Abortion in the United States

    The majority of all pregnancies in the United States can be considered unintended and half of those are resolved by abortion. As indicated earlier, of all the pregnancies in the United States in 1987 (6.3 million), 57 percent (3.5 million) were unintended at the time of conception and, of those unintended pregnancies, 51 percent ended in abortion. Of the total number of pregnancies in 1987 in the United States, 29 percent were terminated by abortion (IOM 1995). The number of reported abortions in the United States increased substantially between 1972 and 1989 in the wake of the 1973 Roe v. Wade Supreme Court decision legalizing abortion. In 1972, approximately 600,000 legal abortions were reported; in 1978, 1.1 million were reported. However, through the 1980s, the annual number of abortions in the United States has remained more or less stable, with approximately a million and a half legal abortions each year during the 1980s; 1.6 million in 1990; and 1.5 million in 1991 and 1992, respectively (Henshaw and Van Vort 1993; Koonin et al. 1992).

    Overall, women undergoing abortions tend to have had no previous live births and are having the procedure for the first time. The majority are unmarried, white, and young (24 percent under age 19, 33 percent between ages 20-24). About half of all abortions are performed before the eighth week of gestation, five out of six before the thirteenth week; younger women tend to obtain abortions later in pregnancy (Koonin et al. 1992).

    From the perspective of proportion of unintended pregnancies that end in abortion, these patterns persist. The most powerful predictor remains marital status: 75 percent of all unintended pregnancies among unmarried women in the United States in 1987 terminated in abortion, compared to 53 and 26 percent among formerly married and currently married women, respectively.

    Age is less consistently predictive. Fifty-one percent of unintended pregnancies among women aged 15-19 and women aged 20-24 end in abortion, then there is a slight decline to 47 and 50 percent in women aged 25-29 and 30-34, respectively. The rates jump to 55 percent in women aged 35-39 and to 59 percent in women aged 40-44; in other words, about 6 out of 10 women aged 4044 who experience an unintended pregnancy seek abortion. Poverty status is the weakest predictor: The percentage of women obtaining an abortion to resolve an unintended pregnancy is only slightly lower among affluent women than it is among low-income women (IOM 1995) (refer back to Table 2-6).

    There has been a slight diminution in the U.S. abortion rate since the early 1980s. However, it remains two to four times higher than rates in other comparable market economies,10 of which very few have abortion rates even approach-

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    ing those in the United States, even though access to abortion in those countries is often easier than it is in the United States (see Table 2-9). The high U.S. rate is not a function of a higher incidence of abortion among minority women, as is often thought to be the case; the U.S. abortion rate is higher overall than rates in other market economies, among whites as well as among all U.S. women. The high U.S. rate is due entirely to its higher total pregnancy rate (average number of pregnancies [births plus abortions]) and the high proportion of those pregnancies that are unintended (IOM 1995).

    All in all, the popular image of the U.S. woman most likely to elect abortion to resolve an unintended pregnancy—the poor minority teenager—is inaccurate (Kaiser/Harris 1995). Substantial percentages of U.S. women in every age and socioeconomic category terminate unintended pregnancies with abortion; even among currently married women, that proportion is still 26 percent.

    Maternal Mortality

    Significant gains have been made in infant and child survival in developing countries over the past few decades; much less progress has been made in maternal survival (Rosenfield and Maine 1985). Recent recalculations by WHO and UNICEF indicate that maternal mortality is higher than previously estimated, with some 590,000 maternal deaths worldwide as of 1990, compared to the 509,000 figure calculated from an earlier model (WHO 1996; WHO 1991). The most significant differences between the old and new models are in Africa; estimates for Asia and Latin America changed little. In Africa, the overall revised maternal mortality ratio11 for 1990 was 880 maternal deaths per 100,000 live births, compared to the earlier estimate of 630 per 100,000, with a range from 1,061 in Eastern Africa to 343 in Northern Africa. The ratio for the less developed regions as a group was 586 maternal deaths per 100,000 live births; the overall maternal mortality ratio for the more developed regions in 1990 was 27 (WHO 1996). Expressed somewhat differently, the chance of dying from pregnancy-related causes between 1975 and 1984 ranged from 1 in 9,850 in Western Europe to 1 in 19 in Western Africa (Herz and Measham 1987). Table 2-8 compares the mortality risks associated with pregnancy and selected health procedures—legal abortion, female sterilization, delivery of live birth, cesarean section, illegal abortion, and hysterectomy—in the United States and in the developing countries.

    These are much greater discrepancies in maternal mortality rates between developed and developing countries than those observed in connection with infant mortality rates (Rosenfield 1989). Furthermore, there are many reasons for believing that these figures are gross underestimates. Even in the United States in the 1980s, official statistics on maternal mortality were thought to underestimate incidence by 20 to 30 percent, with underestimates in the developing world significantly higher (Rosenfield and Maine 1985). This overall picture is compli-

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-9 Abortion Rates per 1,000 Women Aged 15-44, by Country, 1980 and 1985-1992

    Country

    1980

    1985

    1986

    1987

    1988

    1989

    1990

    1991

    1992

    Australia

    13.9

    15.6

    16.4

    16.3

    16.6

    Belgium

    7.5

    Canada

    12.6

    11.3

    11.2

    11.3

    11.6

    12.6

    14.6

    14.7

    14.9

    Denmark

    21.4

    17.6

    17.7

    18.3

    18.2

    Finland

    12.4

    11.7

    11.5

    Francea

    15.3

    14.6

    13.9

    13.3

    13.2

    Federal Republic of Germany (former)a

    6.6

    6.1

    6.3

    6.6

    6.3

    5.6

    5.8

    Irelandb

    4.8

    5.2

    5.2

    4.8

    5.0

    4.9

    5.4

    Italya

    18.7

    16.8

    16.0

    15.3

    15.3

    12.7

    The Netherlandsc

    6.2

    5.1

    5.3

    5.1

    5.1

    5.1

    5.2

    New Zealand

    8.5

    9.3

    10.5

    11.3

    12.8

    12.9

    14.0

    14.4

    Norway

    16.3

    16.3

    17.1

    16.8

    17.1

    17.9

    16.7

    United States

    29.3

    28.0

    27.4

    26.9

    27.3

    26.8

    27.4

    26.3

    25.9

    United States,

     

     

     

     

     

     

     

     

     

    whitesd

    24.3

    22.6

    21.8

    21.2

    21.2

    20.9

    21.5

    20.3

    a Statistics for France, Germany, and Italy may be incomplete.

    b Abortion is illegal in Ireland and the reported rate is based on abortions obtained in England and Wales by women reporting Irish addresses.

    c Data from the Netherlands are for residents only.

    d Data for whites in the United States include most Hispanic women.

    Sources: Alan Guttmacher Institute. Unpublished data, 1994. Henshaw S, E Morrow. Induced Abortion: A World Review, 1990 Supplement. New York: The Alan Guttmacher Institute, 1990. Henshaw S, J Van Vort. Abortion Services in the United States, 1991 and 1992. Family Planning Perspectives 26:100-106: Table 1, 1993. Canadian Center for Health Information. Therapeutic Abortions, 1991. Ottawa, Ontario: Statistics Canada, 1993. United Nations. Abortion Policies: A Global Review. Vol. II. New York: Department of Economic and Social Development, United Nations, 1993.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    cated by the fact that rates in some population subgroups can be significantly higher. In terms of age, a very early first birth increases a woman's risk of dying from pregnancy-related causes, and adolescent first-births and births at the end of a woman's reproductive period generally are associated with a higher likelihood of pregnancy-related complications.12 Residence also skews the numbers, since rural mortality rates are almost inevitably higher, as they are for very underserved urban slum peripheries. What is clear is that, in general, the likelihood that a woman will die in pregnancy or childbirth depends on how many times she is pregnant. This means that the lifetime risk of maternal mortality is many times greater than ratios indicate because the ratio ignores the effect of repeated pregnancies; each pregnancy adds to total lifetime risk (Walsh et al. 1993).

    Sexually Transmitted Reproductive Tract Infections

    Of all the health problems that women confront, infection of the reproductive tract is most closely connected with family planning programs. Reproductive tract infections (RTIs), notably the sexually transmitted reproductive tract infections,13 are also positioned at the nexus between female health, safe motherhood, child survival, and HIV prevention, for each of which they have profound implications (Cates and Stone 1992; Wasserheit and Holmes 1992).

    Reproductive tract infections, particularly those that are sexually transmitted, are hardly new and, until now, have been traditionally unrecognized in most developing countries as either a necessary or an appropriate component of health programs. What is new is the heightened attention accruing to them as a category of "emerging diseases" (IOM 1992). The recognition that sex is the primary mode of transmission of the HIV virus that results in AIDS, together with the size and flow of donor resources to combat that disease, have ratcheted up interest in RTIs in general and sexually transmitted diseases (STDs) in particular. Interest has also been heightened by recognition of STDs as implicated in cervical cancer and, possibly, hepatocellular cancer and, as diagnostic technology has improved, the sheer number—over 50—of STDs has been revealed. Finally, the momentum of demographic change, intra- and international mobility, relentless urbanization, and economic and political volatility have demonstrated that the burden of morbidity and mortality these diseases generate is a large and global matter (Brunham and Embree 1992; IOM 1992a; Over and Piot 1993).

    Any complacency about having conquered the "first-generation" STDs—gonorrhea, syphilis, and chancroid-has been amply challenged both by their recent resurgence virtually worldwide, as well as by a "second generation" of sexually transmitted organisms. The essentially new syndromes associated with four major pathogens—chlamydia, herpes simplex virus (HSV), human papilloma virus (HPV), and the human immunodeficiency virus (HIV)-are more difficult to identify, treat, and control, and they impose a much larger burden of chronic morbidity, disability, and death.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-10 Sexually Transmitted Disease Microbial Agents and the Conditions They Produce in Women and Children

    Etiologic Agenta Conditions

    Acute Disease

    Pregnancy-associated

    Chronic

    Bacteria

     

     

     

    Neisseria

    Urethritis

    Premature delivery

    Infertility

    gonorrhoeae

    Cervicitis Salpingitis

    Septic abortion Postpartum endometritis Conjunctivitis neonatorum

    Ectopic pregnancy Disseminated gonococcal infection

    Chlamydia trachomatis

    Urethritis Cervicitis Salpingitis Reiter's syndrome

    Conjunctivitis Infant pneumonia Postpartum endometritis

    Trachoma Ectopic pregnancy Infertility

    Treponema pallidum

    Primary and secondary syphilis

    Spontaneous abortion Stillbirth Congenital syphilis

    Neurosyphilis Cardiovascular syphilis Gumma

    Viruses

     

     

     

    Human immunodeficiency virus (HIV)

    Acute viral syndrome

    Perinatal HIV Prematurity Stillbirth

    AIDS and related conditions

    Human papillomavirus (HPV)

    Genital warts

    Laryngeal papilloma in infants

    Squamous epithelial neoplasias of genitalia

    Herpes simplex virus (HSV-2)

    Genital ulcer

    Spontaneous abortion Premature delivery Neonatal herpes and associated mortality Aseptic meningitis

    Primary and recurrent genital herpes Neurological sequelae

    Hepatitis B virus (HBV)

    Acute hepatitis

    Perinatal HBV

    Chronic hepatitis Cirrhosis Hepatoma Vasculitis

    a Other bacterial STD agents include Mycoplasma hominis , Ureaplasma urealyticum , Gardnerella vaginalis , Calymmatobacterium granulomatis , and Group B ß-hemolytic streptococcus. Other viral STD agents include cytomegalovirus, molluscum contagiosum virus, and human T-lymphotropic virus (HTLV- 1). Trichomonas vaginalis, a protozoan, and Candida albicans, a fungus, are also STD agents.

    Sources: Brunham RC, JE Embree. Sexually transmitted diseases: Current and future dimensions of the problem in the Third World. IN Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health, A Germain, KK Holmes, P Piot, JN Wasserheit, eds. New York: Plenum. 1992. Cates W Jr. Sexually transmitted diseases. IN Reproductive Health Care for Women and Babies: Analysis of Medical, Economic, Ethical, and Political Issues, BP Sachs, R Beard, et al., eds. New York: Oxford University Press. 1995. Over M, P Piot. HIV infection and sexually transmitted diseases. IN Disease Control Priorities in Developing Countries, DT Jamison, WH Mosley, AR Measham, JL Bobadilla, eds. New York: Oxford University Press, for the World Bank. 1993.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    Sexually transmitted diseases generate a variety of acute and chronic sequelae, particularly for females14 and children (see Table 2-10). In addition, there is an ''epidemiological synergy" between HIV and other STDs, since a number of STDs act in various ways, some poorly understood, as pivotal cofactors in the transmission or acquisition of HIV (Alexander 1990; Laga 1992; Wasserheit 1992). HIV is, of course, incurable and almost inevitably lethal, and perinatal transmission occurs in about 20 to 30 percent of births in each pregnancy to infected mothers (Gwinn et al. 1991). However, a number of other STDs (HSV, HPV, and hepatitis B [HBV]) are also incurable, are transmissible perinatally, and produce high levels of morbidity in both mother and child. And, beyond their large biomedical and emotional burdens, the STDs as a group—particularly HIV/AIDS—produce sizable socioeconomic costs to societies and individuals everywhere; their dimensions are discussed in Chapter 5 (Over and Piot 1993). This is acutely distressing since, at least in theory, all RTIs are preventable or treatable and a number of nonviral infections are curable, although drug resistance is emerging in some strains (Chen et al. 1992; Germain et al. 1992; Stein 1990; Wasserheit and Holmes 1992).

    Like unintended pregnancy, STDs display what has been called "biological sexism," since they discriminate biologically against women. Females and males alike are at risk of sexually transmitted disease. However, female physiology and symptomatology, as well as the behavior patterns associated with these diseases, put females at greater risk of (a) acquiring an STD, especially at an earlier age; (b) acquiring a sexually transmitted infection from any single sexual encounter; (c) more difficult diagnosis; (d) speedier progression of concurrent disease; (e) more severe, long-term, systemic sequelae, including PID, ectopic pregnancy, chronic pain, and cervical cancer; and (f) inappropriate or untimely medical care (Cates and Stone 1992; Hatcher et al. 1994).

    Because both pregnancy and infection are "transmitted" through sexual intercourse, women need three types of effective protection, depending on their own reproductive desires and circumstances. If they do not wish to become pregnant, they require protection against both conception and infection simultaneously. If they have no reason to anticipate sexually transmitted infection, they still may require protection against conception. Finally, if women want to become pregnant but also require protection against infection, they need another kind of protection, usually labeled a microbicide. Women have a much higher risk of acquiring an STD from a single coital event—in the case of gonorrhea, risk of acquisition is 25 percent for men and 50 percent for females—so that every single coital event must be protected.

    At the present time, only abstinence provides complete protection against sexually transmitted reproductive tract infections.15 Male and female condoms, when used properly, also provide good protection, although many women encounter male resistance to using either type of condom. All other contraceptives

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-11 Effects of Contraceptives on Bacterial and Viral Sexually Transmitted Diseases (STDs)

    Contraceptive Methods

    Bacterial STD

    Viral STD

    Condoms

    Protective

    Protective

    Spermicides

    Protective against cervical gonorrhea and chlamydia

    Undetermined in vivo

    Diaphragms

    Protective against cervical infection; associated with vaginal anaerobic overgrowth

    Protective against cervical infection

    Hormonal

    Associated with increased cervical chlamydia; protective against symptomatic pelvic inflammatory disease (PID)

    Not protective

    Intrauterine Device

    Associated with PID in first 20 days after insertion

    Not protective

    Natural family planning

    Not protective

    Not protective

     

    Source: Cates W Jr, KM Stone. Family planning: The responsibility to prevent both pregnancy and reproductive tract infections. IN Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health, A Germain, KK Holmes, P Piot, JN Wasserheit, eds. New York: Plenum Press. 1992.

    provide protection against only some STDs (see Table 2-11), although this is not trivial since other STDs are part of the susceptibility pattern for HIV/AIDS (Laga 1992). In sum, only one modern contraceptive is currently on the market that protects men and women against sexually transmitted disease: the condom, whose protective power depends heavily on perfect use.16 In all cases, women must contend with the power imbalance between the sexes that favors men (Aral and Guinan 1984; Cates and Stone 1992; Larson 1989). Thus, there is a compelling need for safe and effective contraceptive and microbicidal methods that women can use without the cooperation, or consent, of their male partner (Claypool 1994; Stein 1990).

    Involvement of Males in Contraception

    The Alan Guttmacher Institute recently commented that, since men's role in contraceptive use is so typically small, the question about what couples are doing to avoid unintended pregnancies should be, What are women doing? The 1995

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-12 Percentage of Couplesa Using Male Methods of Contraception b

    Country

    %

    Country

    %

    Japan

    54

    Jordan

    5

    United States

    22c

    Pakistan

    4

    China

    12

    Cameroon

    3

    Philippines

    9

    Egypt

    3

    Colombia

    8

    Guatemala

    3

    Thailand

    8

    Indonesia

    2

    France

    7

    Kenya

    2

    Mexico

    6

    Nigeria

    1

    a In the countries of North Africa, the Middle East, and Asia, only currently married women aged 15-49 are included; data for all other countries are for married women and those in other sexual relationships.

    b Male methods include withdrawal, condom, and vasectomy.

    c Data for the United States are from special analyses of the 1988 National Survey of Family Growth, which surveyed 8,450 women of all marital statuses aged 15-44, supplemented by data from other national sources. This figure may be higher: Hatcher et al. give a figure of 25.7 percent for couples (women aged 15-44) in the United States using male methods (Hatcher RA, J Trussell, F Stewart, et al., Contraceptive Technology-16th Revised Edition, New York, Irvington Publishers, 1994, Table 5-1).

    Source: Alan Guttmacher Institute. Hope and Realities: The Gap Between Women's Aspirations and Their Reproductive Experiences. New York: The Alan Guttmacher Institute. 1995.

    Guttmacher analysis of the latest data from the Demographic and Health Surveys (DHS) finds that the proportion of couples relying on male methods-the condom, withdrawal, or vasectomy-ranges from 1 to 12 percent in most countries. In Japan, where the condom is the leading contraceptive method in overall use, the proportion of couples who rely on male methods is 54 percent; in the United States, where the condom and vasectomy are both important, estimates of couple use of male methods range from 22 percent (Guttmacher Institute 1995a) to 27.5 percent (Hatcher et al. 1994)(see Table 2-12). The Guttmacher analysis also found that, in the limited number of countries where the DHS collected such information, even when husbands know of at least one contraceptive method, they do not commonly discuss family planning with their wives, at least as reported by women (see Table 2-13 and Table 2-14).

    In a slightly different set of countries, with only one exception (Burundi),

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    women wanted a smaller family size than did their husbands, although in all the Sub-Saharan African countries women still desired rather large families (see Table 2-15). In this same sample, however, while smaller proportions of husbands than of wives said that they did not want any more children, the differences between husbands and wives in this respect were not very large, ranging from 4 to 9 percentage points (Guttmacher Institute 1995a).

    The presumption has been that men's limited involvement in contraception is driven by the fundamental gestalt that, in virtually all societies, defines the roles, status, and power of females as inferior and subordinate to those of males. This presumption has, in turn, driven the historical emphasis placed by family planning programs on women, to the virtually a priori exclusion of men (Kabeer 1992; Sachs 1994; Sadik 1995). Except for the Population Council's intramural basic science research program, which has included attention to development of male contraceptives, that presumption has also driven the investment in contraceptive research and development, at least partly because of the view that male interest in being involved in contraceptive use was quite limited in most populations. As a consequence, men did not benefit from the first contraceptive revolution.

    That view has been something of a self-fulfilling prophecy (Population Reports 1994) and has been tested in only a fragmentary way; most reports on male attitudes toward contraception have come from women. However, as some countries have gathered data on male perceptions of contraception in connection with the Demographic and Health Surveys, there appears to be more heterogeneity in male attitudes than might be expected, even in Africa, where high fertility has deep cultural and socioeconomic roots (UNFPA 1995). At the same time, there is no question that greater male involvement in contraception is a large and commanding need in terms of public health and the well-being of children and the family.

    The need is no less in the United States, where one in 15 men fathers a child while he is a teenager (Marsiglio 1987) and where attention is now being given to the possibility of expanding family planning clinic services to men (Burt et al. 1994). The rationales include the need to include male partners in STD testing, treatment, and education; adding services for men as part of managed care marketing strategies; and the national emphasis on male responsibility in welfare and child support enforcement programs, an integral part of every welfare reform program currently under consideration by the U.S. Congress (Schulte and Sonenstein 1995). The topic of male participation in contraception is taken up in more detail in the next chapter in connection with the use of male methods and the market for contraceptives.

    Concluding Comment

    At the outset of this chapter, "needs" were defined as "a state of felt depriva-

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-13 Husbands' Involvement in Family Planning Decisions (selected countries)

    Country and Survey Year

    No. of Intervieweesa

    % Who Know of at Least One Method

    % Approving of Family Planning (FP)

    % Who Have Discussed FP with Their Wives in the Last Yearb

    % Who Have Ever Used Contraception

    % Currently Using Contraception

    % Family Member Deciding

    Modern

    Any

    Modern

    Any

    W

    H

    J

    Burundi, 1987

    542

    92

    94

    48

    2

    52

    NA

    NA

    Cameroon, 1991

    814

    74

    37

    30

    17

    48

    6

    20

    Egypt, 1988-1989

    9,000 (women)

    14

    25

    61

    Cairo

    469

    100

    92

    61

    78

    81

    65

    70

    Upper Egypt

    1,053

    96

    84

    47

    52

    56

    40

    44

    4

    59

    36

    Ghana, 1988

    943

    79

    77

    46

    26

    41

    9

    20

    India, 1986 (rural)

    250 (women)

    4

    24

    38d

    Kenya, 1989

    1,170

    95

    91

    65

    35

    65

    25

    49

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    Mali, 1987c

    970

    65

    16

    28

    2

    16

    1

    4

    Morocco, 1992

    47

    Niger, 1992

    11

    Pakistan, 1990-91

    1,354

    79

    56

    14

    18

    25

    10

    15

    Turkey, 1991

     

     

     

     

     

     

     

     

     

     

     

    Semi-urban (women)

    366

    62

    8

    25

    Rural (women)

    358

    29

    23

    46

    Note: NA = not applicable; W = wife, H = husband, J = joint.

    a Husbands, except where otherwise noted.

    b Among those who knew at least one contraceptive method.

    c Includes all men, regardless of marital status.

    d 22 percent of the family planning decisions in rural India in this survey were made by the extended family.

    Sources: Derived from tables in McCauley AP, B Robey, AK Blanc, JS Geller, Opportunities for women through reproductive choice, Population Reports, Series M, No.12, July 1994. Data for Morocco and Niger are from Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences, New York, The Alan Guttmacher Institute, 1995.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-14 Women's Discussion of Family Planning with Their Husbands (selected countries)

    Country and

    Survey Year

    % Using Family Planning

    Among Those Who:

    Discussed with

    Husband

    Did Not Discuss

    with Husband

    Botswana, 1988

    40

    18

    Burundi, 1987

    14

    2

    Ghana, 1988

    24

    7

    Kenya, 1986

    36

    11

    Senegal, 1986

    23

    9

    Sudan, 1989-1990

    19

    3

    Togo, 1988

    39

    31

     

    Source: Based on graphics in Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences, New York, The Alan Guttmacher Institute, 1995 (based on data from Demographic and Health Survey country reports, with special tabulations of the data files for Pakistan).

    tion of some basic satisfaction." We have spoken about the general areas of need that have to do with societal and individual health and options and that make contraception a commanding issue for societies and individuals who wish to use it. We have also indicated that, beyond these general areas of need, there are very specific needs for new technologies that are not now being satisfied adequately. A new approach to estimating the overall unmet need for contraception identifies somewhere around 228 million women worldwide (not men, whose needs must also be taken into separate account) who can fairly be said to be in need of contraception. Overwhelming majorities of women want to control their fertility, even in Sub-Saharan Africa with its traditionally high value accorded to large families. And very large numbers of women, even those who have not yet achieved their desired family size, nonetheless state that they failed in their intentions with regard to their last pregnancy, either because they did not mean to have it at all or because they meant to have it at some later date.

    Another dimension of general need is the sheer number of years women require protection from unintended pregnancy since, somewhat ironically, as completed family size continues to fall worldwide, women's lifetime exposure increases; a woman who wants only two children will require 20 years of protec-

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    TABLE 2-15 Male Perspectives on Desired Family Size

     

    Desired Family Size

    % Wanting No More Children

    Country

    Husbands

    Wives

    Husbands

    Wives

    Niger

    12.6

    8.5

    2

    9

    Cameroon

    11.2

    7.3

    10

    14

    Tanzania

    7.4

    6.4

    17

    23

    Burundi

    5.5

    5.5

    Ghana

    6.6

    5.5

    19

    23

    Pakistan

    5.4

    5.3

    33

    40

    Morocco

    4.1

    3.9

    43

    52

    Kenya

    4.1

    3.9

    44

    52

    Egypt

    3.3

    2.8

    61

    67

     

    Source: Based on graphics in Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences. New York: The Alan Guttmacher Institute. 1995 (based on data from Demographic and Health Survey country reports, with special tabulations of the data files for Pakistan).

    tion from that exposure. This means that, for a number of reasons, the same contraceptive is unlikely to be appropriate for an ever-longer and more biologically various life span, thus requiring a more various set of contraceptive alternatives.

    Ancillary analyses tell us about other aspects of the general need for contraception. These include the women all over the world, still in their teens, whose physical well-being and life chances are at special risk: young women spending longer periods of time before entering into formal union, with a greater amount of sexual activity than seems to have been the case in the past; young women following tradition and continuing to enter union very early; and those young women of whom one-quarter to one-half are having their first child before any formal union. These are not exclusively Third World phenomena: In 1987, 1.2 million pregnancies occurred in the United States among women under 20, almost all of which were resolved outside marriage, with about half of those terminating in abortion. This is, of course, part of a bigger picture: The 1995 projection for the number of abortions worldwide is 52 million-28 percent of the 139 million live births projected for this year-about 21 million of which will be performed in countries where they are illegal and, presumably, unsafe. If so

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×

    many women are resolving their pregnancies in this fashion, one must assume they need contraceptive help.

    In Chapter 5 we will focus on those specific areas that point to a need for new contraceptive technologies, not only because they expand the range of contraceptive options overall, in itself a compelling need, but because they fill needs that are not now being met adequately. These include the need for contraceptives suitable for women who have been exposed to unprotected sexual intercourse, contraceptives with anti-infective properties, and methods for men.

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    ×

    Notes

    • 1.  

      The term ''married" as used in this report includes marriages approved by civil, religious, or other customary practices; cohabiting and consensual unions that are socially recognized; and visiting unions where those are recognized.

    • 2.  

      The "KAP-gap" is defined as an inconsistency between a woman's stated childbearing preference and her practice of birth control as ascertained from surveys of her knowledge, attitudes, and practices (KAP) such as the World Fertility, Contraceptive Prevalence, and the Demographic and Health Surveys. Dixon-Mueller and Germain (1992) distinguish between a "conventional" KAP-gap which refers to women who say they want no more children but are not practicing contraception, and an "instantaneous" KAP-gap, which refers to women who say they want no more children or who want to postpone the next pregnancy, are exposed to the risk of pregnancy, and are not practicing contraception.

    • 3.  

      "Presumed" refers to the fact that it is not absolutely guaranteed that no unintended pregnancy will not occur.

    • 4.  

      Some analysts (Geronimus 1992; Luker 1991) argue that the negative effects of early childbearing may reflect the disadvantaged backgrounds of those adolescents who become parents rather than the timing of the birth itself. Recent analyses of large U.S. national data sets do, in fact, suggest that the negative socioeconomic effects of teenage childbearing are diminished when the mother's prepregnancy characteristics and within- and across-family heterogeneity are taken into account (Hoffman et al. 1993; Geronimus and Korenman 1992 and 1993). Still, so far at least, most researchers using varied approaches and data sets conclude that early childbearing is causally associated with negative outcomes over and above the effects of background (IOM 1995), an association that is much more powerfully true in the developing world (IOM 1996).

    • 5.  

      The National Survey of Family Growth (NSFG) is the most comprehensive source of information available on pregnancy and contraceptive use among reproductive-age women (15-44 years) in the United States. Conducted by the National Center for Health Statistics (NCHS), the survey is federally funded. Surveys were carried out in 1973, 1976, 1982, and 1988; respondents from the 1988 survey were briefly re-interviewed by telephone. The 1973 and 1976 samples were restricted to ever-married women, among whom most childbearing in the country had occurred. In 1982 and 1988, women of all marital statuses were included. The next round of the NSFG was conducted in 1995 and the data are being processed and analyzed. It has been designed to improve abortion reporting, clarify questions on unwanted and mistimed pregnancies, measure women's ambivalent feelings about becoming pregnant, and improve understanding of unplanned pregnancies through better measures of contraceptive use.

    • 6.  

      Women "at risk" of unintended pregnancy are defined as those who (a) have had sexual intercourse; (b) are fertile, that is, neither they nor their partners have been contraceptively sterilized and they do not believe that they are infertile for any other reason; and (c) are neither intentionally pregnant nor have they been trying to become pregnant during any part of the year (Henshaw and Forrest 1993).

    • 7.  

      The sections of this report dealing with unintended pregnancy have relied heavily on the exhaustive analysis of the Demographic and Health Surveys and other national surveys by The Alan Guttmacher Institute, partly in preparation for its recently released study, Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences (1995). Where this is not the case or where a different analytic approach is taken to the Appendix Tables in that report, that is so indicated.

    • 8.  

      According to the World Health Organization, "Data on abortion in general and unsafe abortion in particular are scarce and inevitably unreliable because of legal and ethical/moral constraints which hinder data collection. Under-reporting and mis-reporting are common because women may be reluctant to admit to an induced abortion, especially when it is illegal. Few studies have achieved higher than 75 percent accuracy of reporting and, in some cases, only a quarter of abortions known to have been performed have been admitted to by respondents. In a rare follow-up study of 118 women

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×
    •    

      admitting only to spontaneous abortion in Mérida, Mexico, in 1979, 77 percent later admitted that the abortion had been induced" (WHO 1994). Nevertheless, the WHO document from which this citation was taken is as thorough and recent a compendium as exists anywhere and should be considered definitive at this point in time. Still, as the document itself indicates, the numbers provided, especially the numbers of unsafe abortions, should be considered undercounts. This is so even in the United States.

    • 9.  

      This figure supersedes a prior estimate of 200,000 generated from projections based on hospital records. Three factors should be taken into account in interpreting this number: The possibility of a concomitant underestimate in rural areas owing to under-reporting; the difficulty of distinguishing primary from secondary causes of death; and, most importantly, its direct relation with the total number of annual maternal deaths (WHO/FHE, personal communication, November 1995).

    • 10.  

      The term "comparable market economies" refers to selected European countries and Canada. China, the former Soviet Union and newly independent states of central Europe, and most developing countries report ratios to live births that are significantly higher than those in either the United States or other economically comparable countries (Institute of Medicine 1995).

    • 11.  

      The term "rate" has been traditionally used for this figure; it is, however, really a ratio and measures obstetric risk .

    • 12.  

      However, the largest absolute number of maternal deaths actually occur among low-risk women, since there are so many more low-risk pregnancies altogether, and because the complications of pregnancy, which also occur among low-risk women, cannot be predicted in advance.

    • 13.  

      The reproductive tract infections (RTIs) have been broadly defined to include sexually transmitted infections and infections that are nonsexually transmitted, and comprise three types of infection: (1) sexually transmitted diseases (STDs), such as chlamydial infection, gonorrhea, trichomoniasis (which may or may not be sexually transmissible), syphilis, chancroid, genital herpes, genital warts, and human immunodeficiency virus (HIV) infection; (2) endogenous infections, caused by overgrowth of organisms that can be present in the genital tract of a healthy woman, such as bacterial vaginosis and vulvovaginal candidiasis; and (3) iatrogenic infections, associated with medical procedures, such as female genital mutilation, poor delivery practices, cesarean section, unsafe abortion, and improperly performed pelvic examinations and IUD insertions (Brunham and Embree 1992; Meheus 1992). Of the three types of reproductive tract infections—sexually transmitted, endogenous, and iatrogenic—the majority are sexually transmitted in direct fashion (Brunham and Embree 1992). However, the iatrogenic infections are also important because they are linked to contraception, or the lack of contraception, through sepsis during the medical procedures cited above. Of the eight major STD pathogens producing RTIs, four are bacterial (chancroid, chlamydia, gonorrhea, and syphilis) and four are viral (HIV, human papilloma virus/HPV, herpes simplex type 2/ HSV-2, and hepatitis B/HBV).

    • 14.  

      In the context of the sexually transmitted reproductive tract infections, it is unfortunately necessary at times to use the term "females" rather than "women." Normally, one would expect only women of fertile age to be at risk of such infection. However, rape and other sexual abuse of prepubescent females, as well as female genital mutilation where that is practiced, mean that it is sometimes the case that females—not women-—come to bear a burden of sexually transmitted disease.

    • 15.  

      It is important to note in this context the behaviorally and biomedically significant distinction between abstinence for pregnancy prevention and abstinence for STD prevention: While the former implies only avoiding penis-in-vagina intercourse, the latter implies avoiding vaginal, anal, and oral intercourse.

    • 16.  

      Clinical trials of the protection provided by the female condom against sexually transmitted infections are now in progress, under the aegis of the National Institute of Child Health and Human Development of the U.S. National Institutes of Health.

    Suggested Citation:"3 Contraceptive Technology and the State of the Science: Current and Near-Future Methods." Institute of Medicine. 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC: The National Academies Press. doi: 10.17226/5156.
    ×
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    ×
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    The "contraceptive revolution" of the 1960s and 1970s introduced totally new contraceptive options and launched an era of research and product development. Yet by the late 1980s, conditions had changed and improvements in contraceptive products, while very important in relation to improved oral contraceptives, IUDs, implants, and injectables, had become primarily incremental. Is it time for a second contraceptive revolution and how might it happen?

    Contraceptive Research and Development explores the frontiers of science where the contraceptives of the future are likely to be found and lays out criteria for deciding where to make the next R&D investments.

    The book comprehensively examines today's contraceptive needs, identifies "niches" in those needs that seem most readily translatable into market terms, and scrutinizes issues that shape the market: method side effects and contraceptive failure, the challenge of HIV/AIDS and other sexually transmitted diseases, and the implications of the "women's agenda."

    Contraceptive Research and Development analyzes the response of the pharmaceutical industry to current dynamics in regulation, liability, public opinion, and the economics of the health sector and offers an integrated set of recommendations for public- and private-sector action to meet a whole new generation of demand.

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