FIGURE 2 Contraceptive status of women experiencing unintended pregnancies, 1988. As noted in Chapter 2, the best available estimate of the pregnancies that are unintended is 57 percent. This estimate is based on the 1988 NSFG and supplemented by abortion data from 1987 compiled by The Alan Guttmacher Institute and the Centers for Disease Control. Sources: Harlap S, Kost K, Forrest JD. Preventing Pregnancy, Protecting Health: A New Look at Birth Control Choices in the United States. New York, NY: The Alan Guttmacher Institute; 1991; Mosher WD. Contraceptive practice in the US, 1982-1988. Fam Plann Perspect. 1990;22:198-205.

Figure 2 portrays the relationship between contraceptive use and unintended pregnancy. Using data from the National Survey of Family Growth (NSFG), this figure shows that in 1988 there were approximately 58 million women of reproductive age in the United States (ages 15 to 44) (Tier 1). Six out of 10 of these women reported using contraception; 4 out of 10 reported that they were not currently using contraception (Tier 2). The women who reported using contraception are divided into two groups: those who relied on contraceptive sterilization, either their own or their partner's (Group A), and those who used reversible contraception (Group B). Of these two groups, only the women in Group B have an appreciable risk of becoming pregnant unintentionally, inasmuch as sterilization is so effective.

Similarly, women who reported that they were not currently using contraception are divided into two groups. The first--Group C--is comprised of women who were currently sexually active, were fertile, and were not pregnant, postpartum, or trying to conceive. That is, they were clearly at risk of experiencing an unintended pregnancy because they used no contraception, but at the same time, they reported that they were not actively planning for, or desiring, a pregnancy at that time. The other group, Group D, includes women who were not using contraception, but who were highly unlikely to experience an unintended pregnancy. This group includes, for example, women who were sterile for noncontraceptive reasons, were trying to conceive, had never had intercourse, or were not currently sexually active.

Thus, unintended pregnancy derives almost entirely from two groups. It occurs among women using reversible contraception (Group B), because contraceptive methods may fail or be used improperly. It also occurs frequently among the relatively small group of women using no contraception who nonetheless are not actively seeking pregnancy (Group C), simply because sexual intercourse without the protection of contraception so often leads to pregnancy.

Contraceptive use and unintended pregnancy are influenced by numerous factors: knowledge about contraceptive methods and reproductive health generally, individual skill in using contraception properly, a wide range of personal feelings and attitudes, varying patterns of sexual behavior, access to contraceptive methods themselves, cultural values regarding sexuality, religious and political preferences, racism and violence, the sexual saturation of the media, and others as well. The sheer number and complexity of these forces mean that no single or simple remedy is likely to "solve" the unintended pregnancy problem, particularly because the interrelationships among all of these factors are not well understood. Nonetheless, the voluminous information available, past experience in the public health sector with addressing complex health and social problems, and common sense are all helpful in developing a plan of action to address this important national problem.

The committee has concluded that reducing unintended pregnancy will require a new national understanding about this problem and a new consensus that pregnancy should be undertaken only with clear intent. Accordingly, the committee urges, first and foremost, that the nation adopt a new social norm:

* All pregnancies should be intended--that is, they should be consciously and clearly desired at the time of conception.

This goal has three important attributes. First, it is directed to all Americans and does not target only one group. Second, it emphasizes personal choice and intent. And third, it speaks as much to planning for pregnancy as to avoiding unintended pregnancy. Bearing children and forming families are among the most significant and satisfying tasks of adult life, and it is in this context that encouraging intended pregnancy is so central. Available data clearly indicate that reducing unintended pregnancy will ease many contemporary problems that are of such concern. Both teenage pregnancy and nonmarital childbearing would decline, and abortion in particular would be reduced dramatically. More generally, the lives of children, women, men and their families, including those now mired in persistent poverty and welfare dependence, would be strengthened considerably by an increase in the proportion of pregnancies that are purposefully undertaken and consciously desired.

The U.S. Department of Health and Human Services, through its National Health Promotion and Disease Prevention Objectives, has urged that the proportion of all pregnancies that are unintended be reduced to 30 percent by the year 2000. The committee endorses this goal and stresses that it is a realistic one already reached by several other industrialized nations. Achieving this goal would mean, in absolute numbers, that there would be more than 200,000 fewer births each year that were unwanted at the time of conception, and about 800,000 fewer abortions annually as well.

* To begin the long process of building national consensus around this norm, the committee recommends a multifaceted, long-term campaign to (1) educate the public about the major social and public health burdens of unintended pregnancy; and (2) stimulate a comprehensive set of activities at the national, state, and local levels to reduce such pregnancies.

It is essential that the campaign direct its messages to national leaders and major U.S. institutions, as well as to individual men and women. The problem of unintended pregnancy is as much one of public policies and institutional practices as it is one of individual behavior, and therefore the campaign should not try to reduce unintended pregnancies only by actions focused on individuals or couples. Although individuals clearly need increased attention and services, reducing unintended pregnancy will require that influential organizations and their leaders--corporate officers, legislators, media owners and others of similar stature--address this problem as well. The campaign should also draw on the successful experience of other major efforts to address complicated public health problems, such as the national campaigns to reduce smoking, limit drunk driving, and increase the use of seat belts.

The Campaign to Reduce Unintended Pregnancy

The campaign to reduce unintended pregnancy should stress five core goals, each of which is elaborated in the balance of this summary:

1. improve knowledge about contraception and reproductive health;

2. increase access to contraception;

3. explicitly address the major roles that feelings, attitudes, and motivation play in using contraception and avoiding unintended pregnancy;

4. develop and scrupulously evaluate a variety of local programs to reduce unintended pregnancy; and

5. stimulate research to (a) develop new contraceptive methods for both women and men, (b) answer important questions about how best to organize contraceptive services, and (c) understand more fully the determinants and antecedents of unintended pregnancy.

Before describing these five goals in more detail, it is important to comment on one particular aspect of contemporary American life that may influence the course of the recommended campaign. Over the last decade and more, the age of first intercourse has been steadily dropping, whereas the age of first marriage has been steadily rising, such that there is now an increasing gap between the two events; moreover, there has also been a significant increase in nonmarital childbearing and cohabitation--trends that are not unique to the United States and are, in fact, widely shared by many other countries. Nonetheless, such trends represent major social and cultural changes in the United States and stand in stark contrast to values that were widely shared, at least in theory, throughout much of this century, such as female celibacy before marriage and the unacceptability of young teenagers being sexually active, let alone "living together."

There are many signs that the United States is struggling to come to terms with these new trends and realities. Things are not the way they used to be, but this diverse nation cannot yet seem to agree on what the new rules should be, particularly in the area of sexual behavior. Most probably agree that human sexual expression is a normal and central part of both individual pleasure and species survival, yet the serious issues and repercussions arising from sexual relationships--unintended pregnancy and sexually transmitted diseased (STDs), for example--remain difficult to discuss, and in many instances they are considered controversial. Some urge that we turn back the clock and try to restrict sexual activity to marriage; others espouse a new ethic of sexual activity that emphasizes personal freedom and pleasure, finding little that is worrisome even about childbearing out of wedlock; still others stake out positions somewhere between these first two, trying to make room for nonmarital sexual activity under certain circumstances, but frowning on nonmarital childbearing, for example.

Concern about this underlying disagreement led the committee to three observations. First, the polarizing arguments about sexual activity have obscured common goals that many share, such as the desirability of all children being born into welcoming families who have planned for them and celebrate their arrival. Focusing on this common ground might help to foster a less adversarial, more tolerant environment, and thus make it easier to discuss contraception candidly and directly and to organize a coherent set of intervention programs that are widely understood and supported. It would be particularly helpful if more people understood that the United States does not differ significantly from many other countries in its patterns of sexual activity, but it does report higher levels of unintended pregnancy.

Second, abstinence cannot be counted on as the major means to reduce unintended pregnancy. Most of the men and women at risk of unintended pregnancy are beyond adolescence and many are married, and for this large majority, the primary prevention strategy should be increasing contraceptive use. However, the committee unequivocally supports abstinence as one of many methods available to prevent pregnancy. Furthermore, it urges that young teenagers be counseled and encouraged to resist precocious sexual involvement. Sexual intercourse should occur in the context of a major interpersonal commitment based on mutual consent and caring and on the exercise of personal responsibility, which includes taking steps to avoid both unintended pregnancy and STDs. In this context, it is important to add that the committee did not define the age or life stages at which sexual behavior is appropriate; such decisions are matters best left to family, religious bodies, and other social and moral institutions. This issue is at the heart, however, of the disagreement described above.

Third, it is critically important that officials at all levels of government and public life not misinterpret or over-react to opposition regarding the strategies articulated in this report to reduce unintended pregnancy. Although there are some who object, for example, to comprehensive, high-quality sex education in schools or to helping all sexually active individuals gain access to contraception, these are minority views in many communities and they should not be allowed to paralyze efforts to mount major public health campaigns, such as the one outlined here.

One other comment should be made. Even if all five of the campaign elements outlined above and discussed in detail below were put into place, some number of unintended pregnancies would probably continue to occur. This is because many contraceptive methods have appreciable failure rates even under the best circumstances, and the individuals who use them are not always as careful as is required for maximum efficacy. In addition, there will still probably be some couples who take the risk of using no contraception at all for a period of time, despite having no clear desire to become pregnant. For those women who become pregnant unintentionally, access to both high-quality prenatal care as well as to safe abortion is needed in order to present women and couples with a range of options for managing the pregnancy. Unfortunately, access to both services is limited, especially in some areas of the country, a situation that requires focused attention, advocacy, and resolution. Restricted access to safe, legal abortion, in particular, is often associated with maternal mortality and morbidity, as was the case before the full legalization of abortion in the United States over two decades ago.

* Campaign Goal 1: Improve knowledge about contraception and reproductive health.

An important reason for inadequate contraceptive vigilance, and therefore unintended pregnancy, is that many Americans lack adequate knowledge about contraception and reproductive health generally. The fact that many people mistakenly believe that childbearing is less risky medically than using oral contraceptives is a sobering example of this problem. The resulting fears and misconceptions that stem from such erroneous beliefs can impede the careful, consistent use of contraception, which in turn contributes to the risk of unintended pregnancy.

Accordingly, the campaign should include a series of information and education activities directed to women of all ages, not just adolescent girls, describing available contraceptive methods and highlighting, in particular, the common occurrence of unintended pregnancy among women age 20 and over, especially those over age 40 for whom an unintended pregnancy may carry particular medical risks. Activities should target boys and men as well, emphasizing their stake in avoiding unintended pregnancy, the contraceptive methods available to them, and how to support their partners' use of contraception. And both men and women need balanced, accurate information about the benefits and risks attached to each contraceptive method.

The specific focus on boys and men deserves special emphasis. Males are too often excluded from reproductive health campaigns, even though they often exert great influence on their partners' use of contraception or are themselves active contraceptors. The need to engage males in reproductive health issues is also underscored by data on violence and nonconsensual sex as contributors to unintended pregnancy. Comprehensive education about human sexuality should stress respect for girls and women and the essential role of consent and caring in human relationships, including sexual ones. The data also point to a need for more adult supervision of adolescents, especially young girls, in order to decrease opportunities for coercive or precocious sexual activity.

Parents, families, and both religious and community institutions should be major sources of information and education about reproductive health and family planning, especially for young people, and they should be supported in serving this important function. In addition, U.S. school systems should continue developing comprehensive, age-appropriate programs of sex education that build on new research about effective content, timing, and teacher training for these courses. State laws and policies should be revised, where necessary, to allow and encourage such instruction.

The topic of family life and sex education in the schools has been controversial in some communities; in particular, there is considerable concern that sexual activity may be increased by direct discussion of sexual behavior and contraceptive use. The available data suggest the contrary. Many adolescents become sexually active before having had any formal family life or sex education. Moreover, although there is insufficient evidence to determine whether abstinence-only programs are effective, several studies have shown that sexual activity in young adolescents can be postponed and that use of contraception can be increased once sexual activity has begun by comprehensive education that includes several messages simultaneously: the value of abstinence at young ages especially, the importance of good communication between the sexes and with parents regarding a range of interpersonal topics including sexual behavior and contraception, skills for resisting pressure to be sexually active, and the proper use of contraception once sexual activity has begun.

The committee was impressed by the material suggesting that one of the main information and education sources in the nation--the media--is not helping in the task of conveying accurate, balanced information regarding contraception and sexual behavior, and too often highlights the risks rather than the benefits of contraception. Moreover, the electronic media especially continue to emphasize enticing, romantic, and "swept away" sexual encounters among unmarried couples. Only rarely do they present sexual activity in a manner that supports responsibility, respect, caring and consent, and protection against both unintended pregnancy and STDs. Many television executives decline to advertise contraceptive products because they fear controversy; at the same time, they air advertisements that routinely use sexual innuendo to help sell consumer products and programs that are peppered with sexual activity of all types.

Accordingly, the committee concluded that the electronic and print media should be encouraged to reinforce the material on contraception and reproductive health presented in schools and elsewhere, thereby helping to educate adults as well as school-aged children about these issues. The media should present accurate material on the benefits and risks of contraception and should broaden current messages about preventing STDs to include preventing unintended pregnancy as well. Media producers, advertisers, story writers, and others should also balance current entertainment programming so that, at a minimum, sexual activity is preceded by a mutual understanding of both partners regarding its possible consequences, and accompanied by contraception when appropriate. Similarly, advertising of contraceptive products and public service announcements regarding unintended pregnancy and contraception should be more plentiful.

* Campaign Goal 2: Increase access to contraception.

Through a combination of financial and structural factors, the health care system in the United States makes access to prescription-based methods of contraception a complicated, sometimes expensive proposition. Private health insurance often does not cover contraceptive costs; the various restrictions on Medicaid eligibility make it an unreliable source of steady financing for contraception except for very poor women who already have a child; and the net decline in public investment in family planning services (especially those services supported by Title X of the Public Health Service Act), in the face of higher costs and sicker patients, may have decreased access to care for those who depend on publicly-financed services, particularly adolescents and low-income women. Condoms, the most accessible form of contraception, provide valuable protection against STDs but must be accompanied by other contraceptive methods to afford maximum protection against unintended pregnancy. Unfortunately, other accessible nonprescription methods, such as foam and other spermicides, neither prevent the transmission of STDs nor offer the best protection against unintended pregnancy.

Accordingly, the second focus of the campaign to prevent unintended pregnancy should stress increasing access to contraception, especially the more effective methods that require contact with a health care professional. Financial barriers in particular should be reduced by (1) increasing the proportion of all health insurance policies that cover contraceptive services and supplies, including both male and female sterilization, with no copayments or other cost-sharing requirements, as for other selected preventive health services; (2) extending Medicaid coverage for all postpartum women for 2 years following childbirth for contraceptive services, including sterilization; and (3) continuing to provide public funding--federal, state, and local--for comprehensive contraceptive services, especially for those low-income women and adolescents who face major financial barriers in securing such care.

This last point speaks to the major role that such public financing programs as Title X and Medicaid have played in helping millions of people secure contraception. Although evaluation research has not yet defined the precise effects of these programs on unintended pregnancy, there is no question that they help to finance contraceptive services for many women (and some men), the principal means by which unintended pregnancy is prevented. Whatever the current antagonism to Medicaid and Title X, including suggestions that both be either severely reduced or even eliminated, the important role that they have performed in supporting contraceptive care and related services must be recognized. It is essential that such public investment be maintained. In addition, foundations and government should fund high-quality evaluation studies of the impact that both Title X and Medicaid have on unintended pregnancy and related outcomes. Without better data on the effects of these and other publicly-funded programs active in the area of reproductive health, such programs remain particularly vulnerable to attack, and it is difficult to know how best to strengthen them.

As another way to increase access to contraceptive services, the campaign should also broaden the range of health professionals and institutions that promote and provide methods of birth control. Three steps will help meet this goal. First, medical educators should revise, where necessary, the training curricula of a wide variety of health professionals (physicians, nurses, and others) to increase their competence in reproductive health and contraceptive counseling for both males and females and, when appropriate, in actually providing contraceptive methods. Pediatricians in particular should include pregnancy planning and inter-conceptional care in their routine scope of practice to increase the proportion of pregnancies that are intended (e.g., counseling parents of infants and young children about the benefits of pregnancy planning and spacing for themselves and their young families). Second, administrators should increase the coordination (sometimes even co-location) between basic family planning services and many other health and social programs that often serve individuals at high risk of unintended pregnancy, such as STD clinics, homeless centers, drug treatment centers, WIC offices (that is, offices that provide services financed by the Special Supplemental Food Program for Women, Infants and Children), and well-child and immunization clinics. Third, those who provide social work, employment training, educational counseling, and other social services should be taught (in their initial training as well as through in-service programs) about the importance of talking with their clients regarding the benefits of pregnancy planning and how to do so.

* Campaign Goal 3: Explicitly address the major roles that feelings, attitudes, and motivation play in using contraception and avoiding unintended pregnancy.

Although increasing knowledge about and access to contraception (Campaign Goals 1 and 2) are important first steps, they are not enough. The campaign to reduce unintended pregnancy must also address the fact that the personal feelings, attitudes, and motivations of individuals and couples clearly affect contraceptive use and therefore the risk of unintended pregnancy. Similarly, partner preferences, and particularly the quality of a couple's relationship, are also important influences, as is overall comfort with sexuality; and feelings about specific contraceptives can affect an individual's choice of method and the success with which it is used as well.

In truth, avoiding unintended pregnancy can be hard to do, requiring specific skills and steady dedication over time, often from both partners. The strong, consistent motivation that many forms of reversible contraception require is often fueled by a view of life in which pregnancy and childbearing are seen, at a given point in time, as less attractive than other alternatives. Being pregnant and bearing a child often bring significant psychological and social rewards, and there must be good reason to forego them.

In order to address feelings, attitudes, and motivation more directly, contraceptive services should be sufficiently well funded (through adequate reimbursement rates and/or public sector support) to include extensive counseling--of both partners, whenever possible--about the skills and commitment needed to use contraception successfully. That is, those who teach about contraception as well as those who provide it may well need to spend as much time on issues of motivation, personal feelings, and interpersonal relationships as on the mechanics of contraceptive use. Similarly, school curricula and programs that train health and social services professionals in reproductive health should include ample material about the skills that contraception requires and about the influence of personal factors on successful contraceptive use, along with more conventional information about reproductive physiology and contraceptive technology.

The influence of motivation in pregnancy prevention also underscores the importance of longer-acting, coitus-independent methods of contraception (e.g. hormonal implants and injections and, when appropriate, intrauterine devices) because they require only minimal attention once the method is established. Although few women and couples rely on these methods, their long term potential for reducing unintended pregnancy is great. When offered with careful counseling and meticulous attention to informed consent, these methods constitute an important component of the contraceptive choices available in this country. They do not, however, protect against the transmission of STDs, which requires that condoms be used also.

On a broader level, policy leaders need to confront the notion that, especially for those most impoverished, reducing unintended pregnancy may well require that more compelling alternatives than pregnancy and childbearing be available. Such alternatives include better schools, realistic expectations that a high school diploma will lead to an adequate income, and jobs that are available and satisfying. Increasing knowledge about contraception and improving access to it as well may not be enough to achieve major reductions in unintended pregnancy when the surrounding environment offers few incentives to postpone childbearing. This comment is not meant to suggest that unless poverty is eliminated unintended pregnancy cannot be reduced. The point is rather that, in the poorest communities especially, only modest reductions in unintended pregnancy will likely be achieved by the usual prescription of "more education, information, and services." In this context, it is important to note that research findings do not support the popular notion that welfare payments (i.e., AFDC) and other income transfer programs exert an important influence on non-marital childbearing.

* Campaign Goal 4: Develop and scrupulously evaluate a variety of local programs to reduce unintended pregnancy.

One aspect of the committee's work that it found most puzzling was how little is known about effective programming at the local level to reduce unintended pregnancy. Given all of the public concern about teenage pregnancy, nonmarital childbearing, AIDS, and high-risk sexual behavior, it is quite remarkable that, even using fairly flexible inclusion criteria, the committee was able to identify fewer than 25 programs whose effects on unintended pregnancy, broadly defined, had been carefully evaluated. This lack of program information indicates that there is great need for research to determine various ways to reduce unintended pregnancy. Accordingly, the campaign to reduce unintended pregnancy should encourage public and private funders to support a series of new research and demonstration programs at the community level that are designed to answer a series of clearly articulated questions, evaluated very carefully, and replicated when promising results emerge.

The focus and design of these new programs should be based, at a minimum, on a careful assessment of 23 programs identified by the committee whose effects on specific fertility measures related to unintended pregnancy have been carefully assessed. Evaluation data from these programs support several broad conclusions: (1) even those few programs showing positive effects report only small gains, which demonstrates how difficult it can be to achieve major decreases in unintended pregnancy; (2) because most evaluated programs target adolescents, especially adolescent girls, knowledge about how to reduce unintended pregnancy among adult women and their partners is exceedingly limited; (3) there is insufficient evidence to determine if "abstinence-only" programs for young adolescents are effective, but encouraging results are being reported by programs with more complex messages stressing both abstinence and contraceptive use once sexual activity has begun; (4) few evaluated programs actually provide contraceptive supplies; and (5) only mixed success has been reported from programs trying to prevent rapid repeat pregnancies among adolescents and young women.

The design of these new research and demonstration programs should also reflect four additional themes. First, unintended pregnancies derive in roughly equal proportions from couples who report some use of contraception, however imperfect, and from couples who report no use of contraception at all at the time of conception. Although many individuals move back and forth between these two states over time, it may nonetheless be useful to develop specific strategies for each group, especially for the very high-risk group of nonusers. For example, the former group may benefit particularly from ongoing support and special attention to developing better skills in contraceptive use, whereas the latter group may require a greater focus on underlying psychodynamics and couple interaction. Second, available data suggest that multifaceted programs to reduce unintended pregnancy are particularly effective--that is, programs that include the actual provision of contraceptive supplies, as well as information, education, case management and follow up, ongoing support, explicit attention to underlying attitudinal and motivational issues, and specific training in contraceptive negotiation and skills.

A third theme that should shape these new programs is the need to develop and test out new ways to involve men more deeply in the issue of pregnancy prevention and contraception. Although there is ever more talk about this idea, little investment in program-based research has been made to investigate the effectiveness of various strategies. Some advocate punitive approaches in order to force boys and men to "act responsibly," whereas others are convinced that carrots, not sticks, are needed. Research can help to develop effective interventions, particularly if experimental interventions address men's different ages, life stages, and cultural and personal preferences.

A fourth theme that these programs should explore is how to build community support for contraception. Although contraceptive use is ultimately a personal matter, community values and the surrounding culture clearly shape the actions of individuals and couples. Accordingly, at least some demonstration programs should target both the community and the individual, and some might also work exclusively at the community level. This approach has been used successfully in other areas such as the development of programs to reduce cardiovascular risk factors, and it would be wise to build on this experience for the issue of unintended pregnancy.

Within these broad themes, several additional issues seem particularly important for attention in a new research and demonstration program directed at reducing unintended pregnancy. These include such questions as: How can women over age 35 and their partners, and especially women over age 40, be reached with information and services to reduce unintended pregnancy? Can more "non-health" settings be used to serve adults, such as places of employment or community centers? What ways are especially useful in correcting the serious misinformation that many Americans apparently hold about the risks and benefits of contraception? How can programs effectively combine messages about abstinence with encouragement to use contraception?

* Campaign Goal 5: Stimulate research to (a) develop new contraceptive methods for both women and men, (b) answer important questions about how best to organize contraceptive services, and (c) understand more fully the determinants and antecedents of unintended pregnancy.

The fifth and final prong of the recommended campaign emphasizes research. With regard to the first area, the committee, like many other groups, has concluded that currently available methods of reversible contraception are generally effective but imperfect. Even when used properly, most methods have higher than desired failure rates. Some users balk at a particular method because of its side effects, aesthetic considerations (including whether it interrupts sexual intimacy), or cost. Reliable methods that are highly effective in preventing both pregnancy and STDs are lacking, as are methods that might prevent the spread of STDs but permit pregnancy. Particularly glaring is the lack of effective male methods of reversible contraception other than the condom.

The pervasive importance of personal motivation in contraceptive use underscores the need for more long-acting, coitus-independent methods of contraception. Hormonal contraception via implants and injections has already added important options to the available mix of methods; continuing to refine and improve these methods is essential. There probably is no perfect contraceptive, given the varying needs that both men and women have at different ages and stages of reproductive life, and for the foreseeable future, new methods will be only modest additions to existing options. Nonetheless, even moderate improvements can make an important difference.

The second area of research focuses on learning about how best to organize contraceptive services and highlights the role that health services research can play in reducing unintended pregnancy. Two aspects of such research have already been mentioned: the need for better research and analysis on the effectiveness of publicly-supported programs that help to finance contraceptive services and the need for new research and demonstration programs at the community level to learn more about how to reduce unintended pregnancy. Many other important questions need answers as well: How is access to contraception enhanced or restricted by various managed care arrangements in health care? In which instances is it best to offer contraceptive care as a separate, specialized service and in which cases is it preferable to combine such care with other health services (such as STD services)?

The third area of research addresses gaps in knowledge about the complex cultural, economic, social, biological, and psychological factors that lie behind widely varying patterns of contraceptive use and therefore unintended pregnancy. There are two basic reasons for the limited state of knowledge about the determinants and antecedents of unintended pregnancy--one methodological and the other theoretical. The methodological issue centers on the serious design and measurement problems in most of the existing research on determinants and antecedents. For example, numerous definitions of contraceptive use have been employed; studies typically have been conducted with small convenience samples composed of students or low-income clinic patients; and many studies depend on a single predictor with minimal controls for confounding factors. Even those large-scale surveys that have used representative samples and multiple indicators (such as the NSFG) are limited by their heavy emphasis on social and demographic factors to the virtual exclusion of psychosocial and cognitive factors.

The theoretical issue, perhaps even more important than the methodological one, is that there is insufficient collaboration across disciplines in research on the determinants and antecedents of unintended pregnancy. Conceptualizations are often shaped by the leanings of the researchers' own discipline. Typically, demographers and sociologists have ignored the psychological underpinnings of contraceptive use and unintended pregnancy, psychologists have overlooked the social and demographic factors at work, and economists have limited themselves to economic influences on fertility. Greater interdisciplinary collaboration will be needed to blend these many perspectives into useful predictive models.

Moreover, even though contraception occurs in the context of a social interaction between two partners, few studies have examined men's knowledge, attitudes, and perceptions about contraception and pregnancy; and fewer studies have examined gender differences on these issues. Furthermore, in the majority of studies, data on male involvement have been obtained from the women interviewed, not from men. And little research has been done on couple interaction and decision-making that, for example, explores differing power relationships between the sexes and how age, income and other status inequities affect both sexual behavior and contraceptive use, and therefore unintended pregnancy.

Finally, a new variable has entered into the contraceptive equation: concern for the prevention of STDs, including HIV and AIDS. Although there is an obvious overlap between pregnancy prevention and STD prevention, there are also important differences. For example, the condom is very effective in preventing the transmissions of many STDs, but it is not as effective as some other methods available for pregnancy prevention. By contrast, oral contraceptives are excellent at preventing pregnancy but offer no protection against STDs. So, when only one method is used, rather than a combination that would maximize protection against both consequences, a judgment of some sort is being made between the relative risk and importance of STDs versus the relative risk and importance of pregnancy. Research on the determinants of contraceptive behavior has yet to integrate this new dynamic into existing theories used to explain varying patterns of contraceptive use or method selection.

Research in these areas will be enhanced by more refined and differentiated tools to measure the intention status of a given pregnancy. The new questions being used in the 1995 NSFG to probe intendedness represent an important step forward. Additional work along these general lines merits support.

Although it is unreasonable to think it possible to achieve perfect understanding of all the predictors of unintended pregnancy or the relative importance of each, there are abundant clues and some important leads. More research is needed to understand fully why more than half of all pregnancies in the United States are unintended at the time of conception and, in particular, why it is that half of these pregnancies occur among women who did not desire to become pregnant, but were nonetheless using no method of contraception when they conceived. The committee suspects that the effectiveness of community-based intervention programs to reduce unintended pregnancy will remain modest until the knowledge base in this field is strengthened.

Campaign Leadership

Progress toward achieving the five broad goals outlined above would be enhanced by the existence of a readily identifiable group whose mission is to lead the suggested campaign.

* The committee recommends that an independent, public- private consortium be formed at the national level to lead the campaign to reduce unintended pregnancy.

Funding and leadership of this consortium should be provided by private foundations, given their proven capacity to draw many disparate groups together around a shared concern. Members of this consortium should be recruited from the health and education sectors, from private businesses and institutions, and from religious bodies and the media. Researchers and program administrators in reproductive health should be included along with government leaders (federal, state, and local) from both the executive and legislative branches. Experts in community development, employment training, and related fields of social service will be central to the effort as well. Similar groups that have been formed to address equally complex problems include, for example, the Partnership for a Drug-Free America, and the National Commission to Prevent Infant Mortality, both of which were constituted with broad representation and, in particular, were successful in stimulating the development of parallel groups at the state and local level.

One sector that could be especially effective in this consortium is the "children's lobby," that is, the many groups that speak on behalf of children and their needs. Although groups representing women's issues--reproductive health in particular--have long been vocal in their support of contraception and pregnancy planning, the groups focused on children's issues have been far less visible, especially the maternal and child health community. The national campaign to reduce unintended pregnancy will need their voices as well, not only because of the substance of this issue but also because children's groups have great political appeal and credibility.