Programs to Reduce Unintended Pregnancy
Included in the committee's charge was the mandate to ''describe the range of programs that have been organized in the last 10 years or so to reduce the incidence of unintended pregnancy and, to the extent possible, comment on the effectiveness of various approaches." This chapter addresses that charge by examining two types of programs: major national programs that help to finance contraceptive services (e.g., Medicaid and the Title X program) and a variety of community-based programs that have been evaluated. The chapter includes commentary on the possible economic effects of these programs, given the deep policy interest in this issue.
Although there is no national program whose primary mission is to reduce unintended pregnancy per se, several activities funded at the federal and state levels have great relevance to unintended pregnancy inasmuch as they help to finance contraceptive services. Approximately $622 million in public funds was spent on contraceptive services in 1990 (Gold and Daley, 1991). Many of these funds flowed through several large, national programs: Medicaid and the Title X Family Planning Program serve the greatest number of women, but the Maternal and Child Health Services Block Grant, the Social Services Block
Grant, community health centers, and migrant and rural health centers also help to provide reproductive health services in various ways.1
Title X of the Public Health Service Act was first authorized in 1970 and serves as the backbone of family planning services for many women in the United States. Title X authorizes project grants to public and private nonprofit organizations for the provision of family planning services to all who need and want them, including sexually active adolescents, but with a priority given to low-income persons. The program is buttressed by a training program for clinic personnel and has some community-based education activities as well. Federal monies are provided directly to state and local family planning providers, and state matching funds are not required. In 1990, more than 4,000 family planning clinics received $118 million in Title X support (Ku, 1993). During the 1980s, federal funding fell dramatically and the clinics became more dependent on state, local, and private resources (Gold and Daley, 1991). These family planning clinics served approximately 4.5 million women in 1991, an increase from 3.8 million women in 1981. The majority of family planning clinic clients are low-income women, and approximately one-third are adolescents. The average proportion of male clients served in family planning clinics is approximately 6 percent (Burt et al., 1994).
Medicaid is a national, publicly supported program that provides a unique 90 percent federal matching rate to state expenditures for the family planning care of women enrolled in the Medicaid program. Most public dollars spent on family planning are through the Medicaid program; federal and state expenditures in 1990 were approximately $270 million, serving an estimated 1.7 million clients, of whom 2 percent were men (Gold and Daley, 1991; Ku, 1993). In part because of the expansion in eligibility for pregnant and postpartum women, but primarily because of a rise in the number of people enrolled in Aid to Families with Dependent Children (AFDC), and therefore also in Medicaid, more women began using Medicaid to support contraceptive services in the mid- to late 1980s compared with the number in the 1970s and the early 1980s (Ku, 1993).
The impact of Title X and Medicaid, the two largest public programs, on unintended pregnancy has not been clearly defined, although a number of studies have tried to assess the effect of "publicly supported family planning programs" (which typically include the Title X and Medicaid programs) on various fertility
measures, usually pregnancy and birth rates.2 Two major approaches have been used. In essence, the first approach posits a certain level of effect of family planning programs on fertility, and then, with that assumption in hand, goes on to analyze the effects of publicly funded family planning services on various other outcomes, such as overall welfare expenditures. For example, Forrest and Singh (1990b) hypothesized four possible patterns of contraceptive use that might result from a reduction in public support of family planning programs; each pattern produced a different level of unintended pregnancy, among other things. They concluded that had public sources of contraceptive services been unavailable in the late 1970s, low-income women would have had between 1.2 million and 2.1 million unintended pregnancies, rather than the approximately 400,000 unintended pregnancies that did occur in 1982. Using the same underlying assumptions, they also computed various estimates of cost savings that flow from public investments in family planning, as discussed later in this chapter. Similarly, Levey and colleagues (1988) constructed a detailed algorithm that allows one to estimate the impact of varying expenditure levels for family planning services on other state outlays, such as AFDC, in Iowa.
The other type of research often relies on state or county data and tries to estimate more directly the actual effect of publicly funded family planning programs on selected fertility measures. One such study, completed in the 1970s, examined fertility levels across various geographic areas to assess the impact of family planning programs. The analysis concluded that "the U.S. family planning program has reduced the fertility of low-income women by helping them to prevent unwanted and mistimed births" (Cutright and Jaffe, 1976:100).
Two more recent studies focused on different but closely related outcomes and used the same general methodology. Grossman and Jacobowitz (1981) and Corman and Grossman (1985) clearly documented that organized family planning services reduced both infant and neonatal mortality rates. These gains were probably accomplished, in part, by reducing pregnancies among various groups that are at high risk of such mortality, such as low-income women or those with very short interpregnancy intervals. Because these groups also tend to be at high risk of unintended pregnancy, it is reasonable to suggest that the positive effects observed by these investigators were due in part to reducing unintended pregnancy.
Other studies using state level data have also been completed and, in the aggregate, suggest that publicly funded family planning programs affect some fertility measures more than others. For example, Moore and colleagues (1994)
reported that total public expenditures on contraceptive services (including Medicaid, Title X, and state funds) per woman at risk of unintended pregnancy had no apparent effect on adolescent pregnancy rates, but did seem to have a variable effect on birth rates, differing somewhat by race and age. Singh (1986) also found lower teenage birth rates in states with higher proportions of adolescents served in family planning clinics, but did not find an association with lower pregnancy rates. Similarly, Anderson and Cope (1987) found that publicly funded family planning programs in the United States could be linked to lower birthrates; this analysis did not assess effects on pregnancy rates. Olsen and Weed (1986) also concluded (using 1978 data) that overall enrollment in family planning clinics is associated with reduced teen birth rates, but suggested that such enrollment may also be associated with increased teen pregnancy rates. In a subsequent analysis, these same investigators (Weed and Olsen, 1986:190) seemed to soften their earlier finding by concluding that "greater family planning program involvement does not result in a reduction in teenage pregnancy rates." It is important to add, however, that all of these analyses have some unresolved methodological problems that suggest their conclusions should be viewed carefully. None of them, for example, has been able to control for varying levels of sexual activity, nor do they factor in such other dynamics as the growing use of condoms—widely available outside of organized clinic systems—to prevent pregnancy.3
One of the most recent such investigations is that of Meier and McFarlane (1994). They conducted a state-level analysis to measure the effectiveness of publicly funded family planning during the mid-1980s in influencing a variety of outcomes. The analysis focused on several indicators of effectiveness: the state-level abortion rate, the age-specific fertility rate for adolescents, the incidence of low birthweight and premature births, the proportion of pregnant women receiving late or no prenatal care, and the neonatal and infant mortality rates. The principal measure of public funding was the level of family planning
As noted, these studies rely on state-level data, and this choice of analysis unit has both advantages and disadvantages. The disadvantage is that the outcome indicators of effectiveness are not directly linked to program activities or to the behavior of program clients. Viewed from another perspective, however, the use of state aggregates may be a potential strength. As is argued in Appendix G, the evaluation of any given program is greatly complicated when a number of programs coexist in the same geographic area. For instance, the information provided by one program may encourage a potential contraceptive user to seek out the services that are provided by a different program or by the private sector. These cross-program and spillover effects cannot be captured using program data alone; they require histories of program contacts and service utilization on the part of clients. A state-level analysis is implicitly concerned with the net effects of all publicly funded activities, and may therefore provide a truer picture than would emerge from consideration of any one program in isolation.
funding per capita, a measure that draws together all Title X funds as well as funds from other federal and state sources (see Gold and Macias, 1986; and Gold and Daley, 1991, for discussions of these funding sources). They also defined a second and somewhat problematic measure of public funding: the publicly funded abortion rate. This rate is the ratio of publicly funded abortions in a given year to the number of women aged 15–44 in that year. In addition, the investigators included a set of socioeconomic control variables, such as income per capita in the state, the proportion of the population that is black and Hispanic, and the proportion of the population that is Catholic.
In a pooled regression analysis, they found that increases in family planning funding were associated with a number of beneficial outcomes, such as a reduction in the incidence of low birthweight and reductions in neonatal and infant mortality levels. These effects were statistically significant and, when translated into totals, demographically important. They also found lower abortion rates, and because abortion is in almost all cases a response to an unintended pregnancy, this study suggests that increases in family planning funding reduced the number of unintended pregnancies. Curiously, there is no apparent association with adolescent fertility rates, nor do significant effects emerge with respect to the proportion of births that are premature or the proportion of women who receive inadequate prenatal care.
These conclusions from the analysis of Meier and McFarlane (1994) should be accepted with caution. The regression specification includes the publicly funded abortion rate as an explanatory variable, yet the total abortion rate, to which publicly funded abortions contribute, is treated as one of the dependent variables or effectiveness indicators. Without a reanalysis of these data, it is not possible to say whether their mixing of explanatory and dependent variables renders all conclusions suspect. It would not be surprising, however, if the net effect of the misspecification is to understate the full beneficial impacts of family planning funding.
Again, though, none of these studies focus specifically on Title X or Medicaid. This gap in the literature is puzzling and remarkable. It means, in particular, that the largest public sector funding efforts, Title X and Medicaid, have not been well evaluated in terms of their net effectiveness, including their precise impact on unintended pregnancy. At the same time, it is important to acknowledge how difficult it would be to design an evaluation of either program in the aggregate, although studying effects on unintended pregnancy in small areas is possible and should be done. In any event, these programs clearly help to finance contraceptive services for many women (and some men) and there is a strong suggestion that, as part of overall "publicly funded family planning services," they help to reduce fertility. It is unlikely that careful evaluation would find no net effect on unintended pregnancy.
Assessing the effectiveness of local programs in reducing unintended pregnancy is also difficult, in part because of the sheer number of programs involved. There are, in fact, hundreds of smaller programs ongoing or recently completed in the United States that in some way address unintended pregnancy, and the committee made no attempt to investigate them all in great detail. Rather, the committee's focus was on those whose results have been carefully evaluated, a focus that considerably narrowed the task. In the subsections below, lessons learned from the evaluated programs are discussed. It is important, however, to begin this consideration of local programs with a clear acknowledgment that the existing array of programs at the local level—those that have been evaluated and those that have not—reflects a unique history and, in particular, the changing interests and ideologies of both public and private funding agencies.
There are few references to adolescent pregnancy in the scientific literature before 1960, although there are many references to births among unmarried women (often called "illegitimacy" at the time). In that era, most researchers and program planners appeared to believe that a child's being born to a married woman, rather than the age of the woman, was the major factor determining pregnancy outcomes and life prospects for mother and child.
In the 1960s, however, this began to change. Health, education, and social service practitioners became concerned about the consequences of adolescent pregnancies, and therefore developed programs to assist pregnant adolescents, largely those still under 19 years of age. The emphasis of these early programs was on reducing maternal and infant morbidity and mortality through adequate prenatal care; keeping pregnant adolescents in school during their pregnancies, often through the development of special schools, and returning them to school after delivery of their child; and ameliorating problems in the areas of interpersonal relations, housing, and financial status through the provision of social services. The programs also worked to prevent rapid repeat pregnancies among the participants. Perhaps the first such program was the Webster School, begun in 1963 in Washington, D.C., and funded by the Children's Bureau. Programs in Syracuse, New Haven, Baltimore, and other cities followed, some with federal support, but most with local or, later, state funds.
In 1972, Kantner and Zelnik began to publish their pioneering studies of adolescent sexuality, contraceptive use, and pregnancy; and other researchers began to analyze the epidemiology, risk factors, and outcomes of adolescent pregnancy. In 1971 and 1976, federal agencies developed proposals to address the problem of adolescent pregnancy, but no major initiative was undertaken
until the publication in 1976 of The Alan Guttmacher Institute's report, 11 Million Teenagers: What Can Be Done About the Epidemic of Adolescent Pregnancies in the United States? (The Alan Guttmacher Institute, 1976). A federal task force was then assembled, and its report to U.S. Department of Health, Education and Welfare Secretary Joseph Califano led to the establishment of the federal Office of Adolescent Pregnancy Prevention (OAPP). Shortly thereafter, in 1978, the Adolescent Health, Services, and Pregnancy Prevention and Care Act was passed. Although it included prevention language, the primary emphasis of this act was on demonstration projects that would provide "services to adolescents who are 17 years of age and under and are pregnant or who are parents." Several foundations became interested in this problem and supported demonstration programs largely directed at pregnant adolescents (Klerman, 1981).
The 1981 federal Omnibus Budget Reconciliation Act effectively terminated the original grant program, but OAPP survived and the Adolescent Family Life Act was passed. The act specified that grants should be made for demonstration projects for the provision of prevention services as well as for care services, and stressed the prevention of sexual activity among adolescents (i.e. abstinence) and adoption as an alternative for adolescent parents. Under the terms of the new legislation, grantees could not provide family planning services, other than counseling and referral, unless appropriate family planning services were not otherwise available in the community (Vinovskis, 1988).
The 1981 legislation allowed OAPP to support education programs whose aim was to prevent pregnancy. This was a relatively new role for the federal government since most sex education was assumed to be conducted in schools, by religious organizations, or by families, and the federal role in curriculum development had traditionally been advisory, with state and local governments taking the lead.
Between 1978 and 1984, the Center for Health Promotion and Education at the Centers for Disease Control (CDC) supported research on different aspects of sex education programs. This research was an attempt to understand the range of approaches being used around the nation and to determine their effectiveness. During this time, several not-for-profit, intermediary organizations, such as the Center for Population Options and the North Carolina Coalition on Adolescent Pregnancy,4 were organized to advocate for attention to the problem of teenage pregnancy, to act as intermediaries between policymakers and local program
leaders, to perform research and promote networking, and to provide technical assistance to local agencies.
Major foundations, notably The Ford Foundation and The Robert Wood Johnson Foundation, provided financial assistance to a variety of community organizations to work with schools to open school-based clinics. The possibility that a school-based health clinic could prevent adolescent pregnancy was first suggested by the results of the St. Paul program in 1980 (Edwards et al., 1980). Many local and state agencies followed this lead and organized such clinics. However, school systems, wary of controversy, usually stressed the need to improve adolescent health generally rather than to prevent pregnancy only.
Foundation investments in this field have varied over the years and across individual grant programs, but they, like the government, first stressed care for pregnant and parenting adolescents and then moved gradually to emphasize the prevention of pregnancy among teenagers. The Charles Stewart Mott Foundation, for example, established the Too Early Childbearing Network in 1978. Other large foundations, such as the Carnegie Corporation of New York, The Ford Foundation, and The William T. Grant Foundation, developed demonstration projects to ameliorate the effects of childbearing by adolescents (Klerman and Horwitz, 1992). A more recent move by foundations toward primary prevention programs is exemplified by the development of New Futures and Plain Talk: A Community Strategy for Reaching Sexually Active Youth by the Annie E. Casey Foundation and heavy reliance in the developmental phase of school-based adolescent health centers on the support of The Robert Wood Johnson Foundation.
In sum, the existing network of programs around the country reflects a unique history, particularly the early interest in caring for pregnant adolescents, followed by changing ideologies at the federal level. Reducing unintended pregnancy has rarely been a goal of these community-based, local programs, even though their stated goals, such as reducing repeat pregnancies, are often closely related to unintended pregnancy.
Program Search and Selection
As just noted, few programs at the local level have been explicitly designed to prevent unintended pregnancy. Accordingly, the committee considered those programs whose various outcome measures or stated goals are closely related to reducing unintended pregnancy: (1) raising the age of first intercourse, (2) improving contraceptive use (or, similarly, decreasing unprotected sexual activity), and (3) reducing pregnancy among adolescents, including rapid repeat pregnancy.
The committee further decided that to be considered "evaluated," a program must meet the following criteria: (1) the evaluation was completed since 1980;
(2) the evaluation was performed using an experimental or quasi-experimental design; (3) the evaluation measured behavioral outcomes (e.g., sexual activity or contraceptive use); and (4) the evaluation results were published in peer-reviewed journals.
With these criteria in mind, the committee conducted a national search to learn, in general, about local programs to reduce unintended pregnancy and, in particular, to identify programs whose results had been evaluated. Letters requesting information were sent to the directors of programs receiving Title X funds and the directors of maternal and child health agencies; federal and local government programs were contacted; foundation officers were queried; the primary investigators of several leading initiatives and the project directors of many smaller initiatives were approached; notices asking for program leads appeared in newsletters of the National Association of County Health Officials and the American Public Health Association and online through the Women's Health Network; and relevant literature was reviewed through MedLine, Social Science Index, Sociological Abstracts, Psychological Abstracts, Popline, and Family Resources databases, as well as the Health Promotion and Education Database from the CDC.
This search resulted in the identification of more than 200 programs that in some way address unintended pregnancy. In the aggregate, they represent a wide array of approaches, from school-based condom distribution programs, to classic family planning clinics; from innovative programs of community education to highly targeted interventions to prevent rapid repeat pregnancy among adolescents. Some are well-known and have received significant public attention, such as the "I have a Future" program at Meharry Medical College and the Family Life and Sex Education Program of the Children's Aid Society in New York City. However, only 23 met the committee's evaluation criteria. These programs are a small and unique subset of the many programs now under way that deal with issues of sexual activity and contraceptive use. Nevertheless, because their effectiveness has been assessed carefully, they constitute the available body of knowledge regarding how to intervene effectively at the local level to reduce unintended pregnancy.5 The 23 programs that met the committee's criteria are listed in the following subsection.6
Background information on each program listed below is presented at length in Appendix F, including descriptions of program implementation, objectives, evaluation methodology, results, and primary references.
Community of Caring: several sites around the country providing prenatal care for pregnant adolescents, with an emphasis on planning for future goals, including prevention of repeated pregnancy.
Condom Mailing Program: direct mail program for adolescent men designed to increase their knowledge about and access to condoms.
Elmira Nurse Home Visiting Program: comprehensive program of prenatal and infancy nurse home visitation for low-income women bearing their first child.
Facts and Feelings: home-based abstinence program using sex education videotapes to encourage discussion between parents and young adolescents about sexual issues.
Girls Incorporated Preventing Adolescent Pregnancy: nationwide sexuality education program divided into four age-appropriate components.
Group Cognitive Behavior Curriculum: school-based sexuality curriculum using group cognitive behavior theory to personalize accurate information about sexuality and contraception.
McCabe Center: alternative public school for pregnant students providing prenatal and postnatal education, with an emphasis on delaying rapid repeat pregnancy.
New Chance: national demonstration program offering comprehensive services for low-income parenting adolescents and young adults.
The Ounce of Prevention Fund's Parents Too Soon Program: statewide program for pregnant and parenting adolescents using home visiting and parent groups.
Postponing Sexual Involvement: school-based curriculum encouraging middle school students to delay initiation of sexual intercourse in combination with a human sexuality and contraception component.
Project Redirection: comprehensive demonstration program targeting pregnant and parenting adolescents age 17 or younger, including an employment-orientation component.
Project Taking Charge: school-based program combining abstinence-only sexuality education and vocational education.
Reducing the Risk: school-based curriculum (based on several interrelated theoretical approaches) encouraging avoidance of unprotected intercourse through abstinence or contraceptive use.
Reproductive Health Screening of Male Adolescents: hospital-based reproductive health counseling for adolescent boys, aged 15–18.
School/Community Program for Sexual Risk Reduction Among Teens: community-based program to delay initiation of sexual intercourse and improve use of contraceptives by sexually active adolescents.
Self Center: full reproductive health services as well as health education and counseling services provided through a school-linked clinic.
Six School-Based Clinics: school-based clinics providing comprehensive health care to students located in six sites around the country.
St. Paul School-Based Health Clinics: one of the first school-based health clinic systems in the country providing comprehensive health care, including reproductive health care.
Success Express: school- and community-based program emphasizing abstinence for middle school students.
Summer Training and Education Program: summer school program combining work experience with educational skills and information about responsible sexual decision-making.
Teenage Parent Demonstration: large-scale field test of a change in welfare rules and services, increasing self-sufficiency through enhanced services.
Teen Outreach Project: school-based program involving students in community volunteer service, designed to reduce adolescent problem behaviors.
Teen Talk: sexuality education program based on the health belief model and social learning theory, designed to make adolescents aware of the seriousness of adolescent pregnancy and the probabilities of such a pregnancy happening to them.
In the remainder of this chapter, reference is often made to ''effective" programs. Given the fact that the 23 programs had many different, albeit overlapping, goals, the actual nature of the effectiveness varies from program to program: that is, some were found to delay the age of first intercourse, some were found to improve contraceptive use, and so forth. For simplicity, the specific outcome measures are not always referred to extensively in the text; however, they are described in more detail in Appendix F, and many of the examples used to illustrate cross-cutting themes are careful to specify what effectiveness means for a given program.
It is important to emphasize that these programs are not necessarily effective in achieving their program goals. The committee's criteria asked only that the program be well evaluated, not that it be successful.
A Comment on Program Evaluation
The fact that only 23 evaluated programs surfaced for detailed review merits comment. The limited number should not be construed as an indication that program managers in the area of reproductive health are uninterested in learning
the effectiveness of their efforts, but rather that many obstacles stand in the way of conducting strong program evaluation: (1) cost, (2) methodological difficulties, and (3) a social environment in which research on fertility-related topics may be seen as controversial.
Methodologically rigorous evaluations that incorporate random assignment or the development of a comparison group can be expensive; for example, it is often necessary to hire outside evaluators, especially for smaller programs with limited staff. Few programs have the additional funding readily available in their budgets for such an undertaking, and program staff may be reluctant to spend program dollars on research evaluations that would not immediately translate into the ability to provide more or higher-quality service. In some cases, evaluations are mandated by federal or state legislation, but additional funding is often not provided for in the legislation or is budgeted on an unrealistically low level. This leaves the option of using funds designated for program service, much to the distress of program staff. Sometimes additional funds for evaluation can be raised from, for example, local foundations, but success with such an approach is often limited. This perennial problem in finding or being provided with adequate evaluation financing sets the stage for a particularly distressing sequence of events: a program is put in place without adequate funds for evaluation, and then when it is unable to prove its effectiveness, it is criticized for not knowing what impact it has had.
Most programs target only a small number of people, generally a convenience sample such as students in a classroom or teen mothers receiving public support in a community program. The sample size is usually limited, and often there is a selection bias toward people who want to participate in the program. Small sample size makes it difficult to detect statistically significant differences between intervention and comparison groups. And comparison groups can be difficult to select, in some cases because clinically oriented programs often provide basic health services that might be unethical to withhold. Determining the intervention "dosage," or amount of time spent in a program, is also challenging and must be carefully tracked, because some participants attend all segments of the program and some attend only a few. Similarly, the fact that unintended pregnancy prevention programs often consist of many components makes it difficult to assess the relative effectiveness of each component. It may be that no single component is the most effective piece, but rather that it is the
combination of components that is effective. In addition, longitudinal follow-up of participants is difficult in general, but is particularly challenging in reproductive health programs because of confidentiality issues.
Another problem faced in many program evaluations is that outcome measures are limited to self-reported sexual activity and contraceptive use. Such reports may be unreliable, but there are often no alternative outcome measures available, save the most conspicuous consequences such as sexually transmitted diseases (STDs) and pregnancy. Even these obvious outcome measures can be difficult to assess precisely. For example, although births can be verified through the vital registration system, there is no universal system for reporting abortions or miscarriages, a fact that leads, among other things, to chronic problems in documenting the actual number of abortions performed annually in the United States, as discussed in Chapter 2.
These considerations argue in favor of evaluating only a few large, multisite, model programs relying on experienced evaluators having resources sufficient for the task. Stahler and DuCette (1991) suggest that individual programs should focus attention on process evaluation (i.e., the careful collection of data on client characteristics and service utilization) and that third parties should undertake well-funded impact evaluations (i.e., outcomes and long-term follow-up) of various program models that target different subpopulations.
Evaluation of local programs has also been impeded by the prevailing societal environment. The past 10 or 15 years has not been an era hospitable to research that might be seen as sex-related and therefore controversial. For example, very little survey and ethnographic research on sexuality has been done in the past two decades. Not only is it controversial politically to conduct research on sex-related issues, but involving adolescents in such research, particularly without parental consent, can raise legal issues as well.
During the 1980s especially, the federal government severely curtailed systems of data collection that had been used to monitor a wide variety of programs related to fertility, such as the national family planning reporting system. The view seemed to be that because such programs were seen by some public officials as objectionable, it was best to down play or ignore them altogether by, among other things, collecting little information on their activities or effects. Thus, the fact that only 23 programs met the committee's evaluation criteria may reflect more the political climate within which pregnancy-related programs have recently operated than a disinclination among program leaders to evaluate their activities. In addition, during the 1980s, the withdrawal of much federal funding from all but abstinence-only programs may have had a chilling
effect on program directors and researchers who might otherwise have been inclined to evaluate their programs.
Several cross-cutting themes emerged from a review of the 23 programs, offering clues for future intervention programs as well as for supportive public policies.
1. Knowledge about how to reduce unintended pregnancy at the local level is very limited. Only 13 of the evaluated programs (programs B, C, E, F, G, I, J, M, N, O, P, V, and W) were even somewhat effective in changing sexual and/or contraceptive behaviors that increase the risk of unintended pregnancy. Thus, knowledge about how to reduce unintended pregnancy through local programs is still quite limited. It is also apparent that even among those programs that did report varying degrees of success, the magnitude of impact was sometimes small. Success in raising the age of first intercourse, for example, is typically measured in increments of months, not years, as was the case with the Self Center. Small effects can translate into a reduced risk of unintended pregnancy at the individual level if a delay in the age of first intercourse, for example, also has the effect of increasing contraceptive use once sexual activity begins; nonetheless, the overall demographic impact of such small changes is apt to be minor.
2. Because most of the evaluated programs target adolescents, especially young women, knowledge about how to reach adult women or men is exceedingly limited. Although the large national programs mentioned above (e.g., the Title X and Medicaid programs) do help adult women and a very few men to gain access to contraception, almost none of the 23 evaluated programs operating at the local level has a clear focus on adults (even though a few programs include some adult women who became pregnant as adolescents). This reflects the history of program funding and development presented earlier and mirrors ongoing public concern over adolescent pregnancy, despite the fact that adults also become pregnant (or cause pregnancy) unintentionally and with serious consequences (Chapters 2 and 3).
Too little is known about meeting the reproductive health and contraceptive needs of adult men in particular. The two evaluated programs that did target men concentrated exclusively on adolescents. The Condom Mailing Program, for example, used direct mail to increase adolescents' knowledge about and access to condoms (Kirby et al., 1989), and the Reproductive Health Screening of Male Adolescents program used a hospital-based sexuality education program to increase contraceptive use among adolescent boys (Danielson et al., 1990). In
general, however, adult men are invisible in the 23 evaluated programs. It seems, in some sense, that programs do not know what to do with men, save to provide them with condoms. It is possible, however, that programs could be developed to educate men about their own and their partners' reproductive lives, that men could be encouraged to offer increased personal and financial support for their partners' use of contraception, and that they could be drawn into a wider variety of reproductive health programs. There is some evidence of new interest in programming for males, but it is too soon for evaluations of recent efforts to have been completed (Edwards, 1994).
Few of the 23 evaluated programs target couples, or address male-female decision-making about contraception and pregnancy, despite the fact that sexual and contraceptive decisions often occur within the context of a couple. Although some programs focused on adolescents do seem to address the interaction of the couple, the context is usually to support girls in resisting sexual advances and in saying no to precocious sexual activity. These are exceedingly important skills, but it might also be helpful for individuals and couples to learn about non-adversarial cooperation and communication about sexual and contraceptive issues.
3. There is insufficient evidence to determine whether abstinence-only programs have been effective in increasing the age of first sexual intercourse. Abstinence is frequently emphasized in programs for young adolescents, and it is an important option at all life stages. As noted earlier in the historical review, a number of local programs (such as programs D, L, and S) were funded in the 1980s to stress abstinence as the only means of avoiding unprotected intercourse. Many of these programs were funded by OAPP through the 1981 Adolescent Family Life Act and funding recipients were required to evaluate the effectiveness of abstinence-only programs. To date, these evaluations are too weak to provide evidence for or against the ability of abstinence-only programs to help adolescents delay the onset of sexual activity.
One example of this approach is Success Express, an abstinence-only, school-based program for sixth through eighth graders. This program used a curriculum focusing on family values and self-esteem, pubertal development and reproduction, communication strategies and interpersonal skills about "how to say no," examination of future goals, the effects of peer and media pressures, and complications of premarital sexual activity, adolescent pregnancy, and STDs. Although the evaluation was carefully developed by using a quasi-experimental design, post-test data were gathered immediately following the 6-week intervention; no follow-up data were collected at a later point. It is not surprising that such short-term results showed no significant difference in timing of first sexual intercourse between the intervention and control groups (Christopher and Roosa, 1990; Roosa and Christopher, 1990). The only
significant finding was that boys in the intervention group were more likely to participate in precoital sexual behaviors than were boys in the comparison group.
Another abstinence-only, school-based program, Project Taking Charge, combined sex education and vocational training for low-income seventh-grade students. The program was designed to promote abstinence from sexual activity through promotion of communication between adolescents and their parents and planning for the future in the world of work. Basic sexual anatomy and sexual development were taught, but contraception was not a part of the curriculum. At both 6 weeks' and 6 months' post-intervention, the evaluation found no significant differences in the sexual behaviors of the intervention and comparison groups, although the results indicated that students in the intervention group may have delayed the initiation of sexual intercourse. However, the small sample size limits the generalizability of the results (Jorgensen, 1991; Jorgensen et al., 1993).
A home-based abstinence-only program, Facts and Feelings, distributed a videotape designed to encourage parents and their seventh and eighth graders to discuss sexual issues before the youths' initiation of sexual intercourse. The objective of the program was to encourage discussion about sexual issues between the parents and the adolescent, and the long-term goal was to reduce early adolescent sexual behavior. The videotape promoted abstinence and did not include contraceptive information. At the 1-year follow-up, similar rates of adolescent sexual activity were found in the intervention and control groups (Miller et al., 1993).7
In the aggregate, the evaluations of programs that encourage abstinence only (with no additional material on contraception) provide insufficient evidence to determine if the programs delayed the initiation of sexual intercourse or reduced the frequency of intercourse. More research is needed to understand the impact of these programs more precisely.
4. Sexuality education programs that provide information on both abstinence and contraceptive use neither encourage the onset of sexual intercourse nor increase the frequency of intercourse among adolescents. In fact, programs that provide both messages appear to be effective in delaying the onset of sexual intercourse and encouraging contraceptive use once sexual activity has begun, especially among younger adolescents.
Concern has been expressed that sexuality education leads to earlier sexual intercourse. Ten of the 23 evaluated programs (programs B, E, F, J. M, N, O, P, Q, and W) were sexuality education programs that taught students about the benefits of abstinence for young adolescents as well as the benefits of contraceptive use once sexual activity had begun. All of these programs reported that the onset of sexual intercourse was not higher for the intervention group, nor was the frequency of intercourse higher for the intervention group. In fact, 7 of the 10 intervention programs (programs B, J, M, N, O, P, and W) had outcomes that can decrease the risk of pregnancy, such as raising the age of onset of sexual intercourse, decreasing the mean number of acts of sexual intercourse, and increasing contraceptive use among those students who were already sexually active. The remaining three programs (programs E, F, and Q) had mixed results, but in no instance was the onset of sexual intercourse earlier for the intervention groups.
Although these programs have been criticized for sending confusing messages about sexual behavior to adolescents ("don't do it, but if you do, protect yourself"), program evaluations indicate that adolescents do not have difficulty absorbing this two-part message or sorting through the information to find the material most relevant to their own situations. In addition, a recent worldwide literature review concludes that there is no support for the notion that sexuality education encourages the initiation of sexual intercourse or increased sexual activity. Even in the face of different methodologies and study locales, the aggregate effect of sexuality education is in the direction of postponing first sexual intercourse and using contraception more effectively (Grunseit and Kippax, undated).
One of the best known evaluated programs in the United States that explicitly includes information on both abstinence and contraceptive use is Postponing Sexual Involvement: An Education Series for Young Teens. This program includes two components: one on postponing sexual involvement and one on human sexuality. The first component emphasizes that abstinence is the best choice for young adolescents, and the second component provides basic information on reproduction and contraception. This combination has been shown to be effective: fewer members of the intervention group than those not offered the combined course initiated sexual intercourse, and contraceptive use was higher among sexually active students in the intervention group than in the comparison group.
The Reducing the Risk program also illustrates the effectiveness of the dual message. This curriculum was based on several interrelated theoretical approaches and explicitly emphasized that adolescents should avoid unprotected intercourse, either through abstinence or by using contraception. Results indicated that significantly fewer students in the intervention group than in the comparison group became sexually active. Of the students who did report being
sexually active, significantly fewer reported the practice of unprotected sex, either by delaying first intercourse or by increasing contraceptive use.
Not all programs offering dual messages have had such clear success, however. For example, Teen Talk, a school-based program that uses small group discussions as a key feature, had mixed results. The curriculum was designed to make adolescents aware of the seriousness of adolescent pregnancy and the probabilities of such a pregnancy happening to them, as well as the benefits of and barriers to abstinence and contraceptive use. The evaluation revealed that young men in the intervention group were significantly more likely to have abstained from sex than were young men in the control group. Young women in the intervention group, on the other hand, were no less likely to begin sexual activity than young women in the control group, and furthermore, among the participants who became sexually active following the program, the women in the control group were significantly more likely to have used contraception at last intercourse than those in the intervention group.
Sexuality education in school-based settings was considered carefully in a comprehensive review by Kirby and colleagues (1994). The researchers identified studies of school-based sexuality education and HIV-AIDS education programs and summarized the results; although they looked at a slightly different program universe than the 23 programs reviewed here, the overlap is considerable. Consistent with the analysis presented in this chapter, they learned that none of the programs that discussed both abstinence and contraception significantly hastened the onset of intercourse. Nor did the programs change the frequency of intercourse among those students who were sexually experienced prior to receiving the curriculum. Some programs also increased contraceptive use among students who were sexually inexperienced at the onset of the program. They conclude that, overall, effective programs:
- focus specifically on reducing sexual risk-taking behaviors that might lead to unintended pregnancy or HIV or STD infection;
- use social learning theories as a foundation for program development;8
- provide basic, accurate information about the risks of unprotected intercourse and methods of avoiding unprotected intercourse through experiential activities designed to personalize this information;
- include activities that address social or media influences on sexual behaviors;
- reinforce clear and appropriate standards to strengthen individual values and group norms against unprotected sex;
- provide modeling and practice of communication and negotiation skills; and
- provide training for program implementation.
5. Even though most of the evaluated programs encourage contraceptive use in some way, there is a notable reluctance to actually provide program participants with the contraceptive methods themselves or even to help participants gain access to contraceptive services at some other site. Only nine evaluated programs (programs B, E, H, K, O, P, Q, R, and U) make a clear effort in at least some of their sites to provide contraception or increase access to it. This reluctance is due, in part, to the preponderance of programs targeting adolescents and the ongoing public debate about the appropriateness of providing sexually active, unmarried adolescents with contraceptives.
Even among the evaluated programs working with adolescents who are pregnant or are already parents—a group well known to be at risk of rapid repeat, often unintended pregnancy—the direct provision of contraception is not universal. Only three of seven programs (programs H, K, and U) working with pregnant or parenting adolescents actually provide methods of contraception or direct access to contraception, and two of these three programs (programs H and K) did not provide contraception at all program sites.
The School/Community Program for Sexual Risk Reduction Among Teens reveals the importance of actual access to contraception. This schooland community-based program was designed to reduce high rates of adolescent pregnancy and was a collective effort of parents, teachers, students, clergy, and community leaders. Contraception was made accessible to the students through a school nurse, who provided counseling for the students, condoms for sexually active young men, and transportation to the county health department family planning clinic for sexually active young women. The first evaluation of the program's effectiveness noted that in the 2 years following initiation of the education program developed by the community consortium, pregnancy rates among adolescent girls in the intervention area dropped significantly (Vincent et al., 1987). A reanalysis of this program confirmed that the adolescent pregnancy rate did indeed decrease during the years covered by the earlier evaluation (1984–1986). However, the reanalysis found that in subsequent years (1987–1988), the adolescent pregnancy rate in the intervention area increased to levels that were not significantly different from the pre-program rates. The authors
suggest that this increase probably occurred because, in these later years, there was a general decrease in the program's overall momentum and, in particular, the school-based clinic stopped providing students with contraceptive methods and no provision was made to help them gain access to contraception elsewhere in the community (Koo et al., 1994).
Although the provision of contraception in school-based and school-linked health clinics receives significant media and political attention, only 21 percent of the approximately 500 school-based health clinics around the country actually dispense contraception (Dryfoos, 1994); one study suggests that family planning programs are the weakest component of school-based adolescent health centers (National Research Council, 1993). Evaluations from the three school-based or school-linked programs that provide reproductive health services (programs P, Q, and R) indicate that such programs do not encourage the onset of intercourse, nor do they increase the frequency of intercourse. The evidence is mixed, however, on the capacities of these programs to decrease pregnancy rates.
The Self Center is an example of one school-linked program for adolescents that did appear to decrease pregnancy rates by providing full reproductive health services as well as health education and counseling services to adolescents. Most services were offered in a school-linked clinic located close to both a senior and a junior high school. The program stressed messages of abstinence for young adolescents and contraceptive use for sexually active adolescents. At the 3 year follow-up, significantly more students in schools linked to the clinics attended a clinic before beginning sexual intercourse or attended a clinic during the first months of sexual activity, a period during which unintended pregnancy is especially likely to occur. A significant delay in the initiation of sexual intercourse for young women in the intervention schools was noted; the median delay was 7 months. A significant increase in the use of contraception at last intercourse was noted among both adolescent women and men. A significant reduction in pregnancy rates among the older adolescents in the intervention schools relative to that among older adolescents in the control schools, and a small decrease in the pregnancy rates among younger adolescents in the intervention schools, was found, whereas the pregnancy rates in the control school increased dramatically. Zabin and colleagues (1986:124) suggest that "it was the accessibility of the staff and of the clinic, rather than any 'new' information about contraception, that encouraged the students to obtain service." By contrast, evaluation results have differed about whether or not the St. Paul School-Based Health Clinics reduced pregnancy rates, and the six school-based clinics reported mixed results on contraceptive use.
The impression gained from all 23 program evaluations considered as a whole is that too few include actual, tangible assistance in helping participants to obtain contraceptive supplies. Program personnel often talk about contraception, and also counsel program participants about the methods available. But such encouragement is not uniformly accompanied by actually providing
individuals with contraceptive methods or by focused efforts to link them to a source of contraceptive services, such as a family planning clinic.
6. About half of the evaluated programs attempting to reduce rapid repeat pregnancy, especially among adolescents, have been successful. Much effort has been expended in developing programs to mitigate the negative consequences of childbearing among adolescents and to reduce rapid repeat childbearing during adolescence. In the 1970s, the primary objective of many of these programs was the healthy birth of a child, but more recently emphasis has been placed on the young mother's needs post-delivery. Programs have become increasingly comprehensive, with an emphasis on education, employment, the child's developmental needs, and reducing subsequent pregnancy.
Seven of the 23 evaluated programs (programs A, C, G, H, I, K, and U) attempted to reduce rapid repeat pregnancy, and they share a common emphasis on attaining educational goals and increasing employability. Only three programs (programs C, G, and I) succeeded in helping young mothers postpone rapid subsequent births, and, interestingly, two of these three programs (programs C and G) took a health-oriented approach, such as involving nurses in contraceptive counseling, as distinct from relying exclusively on employment counselors, for example, to encourage contraceptive use.
The Polly T. McCabe Center, an alternative school for pregnant adolescents, is an example of one of the successful efforts that included a health orientation in its postnatal care. The program provided case management by nurses and social workers for up to 4 months after delivery, and such care included follow-up counseling about contraceptive choices made at the hospital, to ensure that the young women felt comfortable with their contraceptive method and knew how to use it most effectively. At both 2 and 5 years, students in the intervention group were significantly less likely to have another child. The researchers note that ''the most surprising finding in this study was that relatively brief postnatal intervention with new adolescent mothers significantly reduced their likelihood of subsequent childbearing over the next five years" (Seitz and Apfel, 1993:578). They suggest that the critical period is the second month following the birth of the first child, in that this typically marks the end of the postnatal recovery period and sexual activity often resumes.
Project Redirection, which did not have a health orientation, is an example of one of the four programs (of seven) that did not succeed in reducing rapid repeat pregnancy. This was one of the first major demonstration projects to include employment issues as part of the care and counseling offered to school-age pregnant and parenting adolescents. Young women in the program were offered a range of services and were supported by community women volunteering to act as mentors. Although the 1-year evaluation results indicated that adolescents in the intervention group were significantly less likely to have a repeat pregnancy, the 5-year evaluation results gave a less positive picture. These longer term results showed that although the intervention group had an
equal number of pregnancies compared with the number in the comparison group, they had fewer abortions and thus more births. Polit (1989:169) notes that "the larger number of children born to Project Redirection participants could … reflect the failure of the family planning component. The approach taken by program staff in the Project Redirection sites was 'low-key,' one that reflected (at least in part) the discomfort of some staff members about discussing issues relating to sexuality. Such an approach appears to have been insufficient to motivate the participants to use effective contraceptives regularly."
New Chance is another example of a program that was not successful in reducing rapid repeat pregnancies among a sample of women who gave birth in adolescence. Program goals included increasing the economic self-sufficiency of adolescent mothers, helping them become effective parents, enhancing the development of their children, and delaying repeat pregnancies. Program participants reported both a higher pregnancy rate and a higher rate of abortion; therefore, comparable rates of repeat childbearing (approximately 25 percent) were found in both intervention and control groups (Quint, Polit, et al., 1994).
7. Little is known from the evaluated programs about how to influence sexual behavior or contraceptive use by changing the surrounding socioeconomic or cultural environment. The objective of most evaluated programs is to affect the actions of individuals by working directly with them rather than by changing the cultural milieu in which they live. No evaluated programs address the sociocultural environment in which sexual decision-making takes place; thus, nothing is known about how, or even whether, to try to influence the surrounding culture as one way of changing sexual and contraceptive behavior.
The analysis of the Summer Training and Education Program (STEP) elucidates this point. Program leaders have hypothesized that the failure to seek any major environmental change was one reason for the program's lack of success. STEP combined work experience for adolescents with educational skills and information about responsible sexual decision-making. The evaluation found that although students in STEP gained significant life skills, no significant differences in sexual behavior were noted between the intervention and comparison groups. Walker and Vilella-Velez (1992:64) suggest that this is because no influence was made on "schools, peers, neighborhoods, family, family income, and perceived and real future job opportunities … almost half of the adolescents who dropped out of STEP cited the need for income or other causes in their environment as their primary reason for dropping out of school."
A notable exception to the pervasive emphasis on individuals is The Media Project, part of the nonprofit organization Advocates for Youth. Although not included in the 23 evaluated programs, this is one activity that has attempted to change the almost constant barrage of sexually enticing messages presented by the media. To do so, program staff work with, for example, writers, directors, and producers of television soap operas and situation comedies, providing them
with information about responsible sexual behavior, including contraceptive use. The Media Project has not been evaluated in any substantial way.
It may well be that community-based programs are not the right mechanism for attempting broad cultural change. These programs are often small, involving a few hundred people or less, and they last only a few years. Programs designed to change individual behaviors may never be able to achieve more than marginal success in a society whose health care system, available information and education, and overall socioeconomic and cultural environments do not uniformly support careful use of the best methods of contraception, as discussed in Chapters 5, 6, and 7.
The Fiscal Impact of Family Planning Funding
Policymakers are understandably interested in the budgetary impact of public investments in family planning programs, both those that operate at the national level and those that work in states and communities. A series of studies has attempted to assess the net fiscal impact of family planning funding, typically by asking: How does an extra dollar of public funding for family planning affect all public outlays for other health and social services? (The techniques and concepts that are involved in establishing program cost-effectiveness are discussed at length in Appendix G).9 Recent studies of fiscal consequences have been
undertaken by, among others, Levey and colleagues (1988), Forrest and Singh (1990a,b), Vincent and colleagues (1991), Fitzgibbons (1993), Olds and colleagues (1993), and Trussell and colleagues (1995). These studies conclude that public expenditures in support of family planning are more than offset by the savings that are produced in other health and social services spending. Depending on the study, these services include the Medicaid, AFDC, food stamp, and Women with Infants and Dependent Children (WIC) expenditures associated with pregnancy, the medical expenditures associated with abortion or childbirth, and the programs that support low-income mothers and their infants and children.
The results of Forrest and Singh (1990b) can serve as an illustration of the nature of the findings in general. According to the authors, "for every government dollar spent on family planning services, from $2.90 to $6.20 (an average of $4.40) is saved as a result of averting [short-term] expenditures on medical services, welfare and nutritional services" (Forrest and Singh, 1990b:6). The range of such estimates found in the literature is great, and the figures depend on details in the assumptions employed and the range of health and social services under consideration. Nevertheless, given the entitlement nature of many of the services in question, family planning efforts would seem to make good sense from the viewpoint of a taxpayer concerned with government budgets (Levey et al., 1988).
Before the assumptions and the data that support this conclusion are assessed, a brief preface is in order. The taxpayer's benefit—cost approach, however useful as a device for marshaling political support, is a specialized and, in some respects, rather peculiar metric for evaluation. It frames the evaluation issue very narrowly, being concerned only with the impact of one form of public expenditure on another form. There is no clear or necessary relationship between the claims that programs make on government budgets and their cost-effectiveness or social desirability. A program that, from the social point of view, is so cost-ineffective that it should not be undertaken may nevertheless reduce claims on government budgets. Conversely, a program that is socially beneficial may increase claims on budgets. Thus, the terms benefit and cost that appear in a taxpayer's benefit—cost analysis bear no obvious correspondence to social benefits and costs. Having issued this warning about the interpretation of taxpayer benefit—cost analyses, some of the common features of these studies and avenues for further work can be addressed.
Program Reactions to Funding Withdrawal
A common assumption in studies of fiscal effects is that the withdrawal of public funding would simply cause the clinics or programs in question to vanish.
Program clients would then need to seek out services elsewhere, and would usually receive services on less advantageous terms. This assumption requires some justification and clarification.
First, it envisions an extreme case, in that total funding withdrawal would be a sharp departure from the current state of affairs. If the aim is to predict net fiscal impacts, a safer approach is to predict the impact of a marginal withdrawal of funds, for example, a cutback of 10 percent.
Second, no attempt is generally made to predict the reactions of clinics and programs to the withdrawal or reduction of state or federal support. Yet, as the experience of the late 1980s shows (Donovan, 1991), programs faced with declines in external support tend to rely more on fees for service, and may also make adjustments in services they provide and their referral practices. To explore the full consequences, two issues need to be identified: (1) the types of changes in pricing and service delivery that are feasible and how likely the different program reactions may be and (2) how women will react to the new provider prices and characteristics. These issues require, at a minimum, consideration of the price-responsiveness of demand for contraceptive services and reproductive health services more generally.
Treatment of Mistimed and Unwanted Pregnancies
A recurrent theme in this report is the importance of distinguishing between pregnancies that are mistimed and those that are unwanted. The distinction surfaces here with respect to the fiscal implications of preventing unintended pregnancies. If the pregnancy that is prevented by contraception was unwanted, then its prevention certainly reduces all future claims on Medicaid, AFDC, and the like. If the pregnancy in question was mistimed, however, these claims on budgets may only be deferred into the future. In other words, prevention of a mistimed pregnancy may well reduce claims on this year's budget; it does not necessarily reduce claims on future budgets.
Two points are therefore at issue. The first is whether to discount claims on all future budgets attributable to prevention, perhaps expressing the net public sector savings in terms of present values. It may be that when pregnancies are properly timed the likelihood of claims on public programs is much reduced. Discounting is therefore not only a matter of present versus future budgets. It also has to do with individual poverty dynamics and the likelihood that a properly timed pregnancy will coincide with periods of (relatively) high income, that is, income high enough to reduce or eliminate claims on AFDC and other income-conditioned services. The second point concerns the budget period envisioned in the fiscal evaluation. If the fiscal impact question is posed as "do family planning expenditures in this fiscal year reduce claims on budgets in this year and the next?", then it may well be reasonable to aggregate mistimed and
unwanted pregnancies in the analysis. If, on the other hand, the time period envisioned in the analysis is longer, then the distinction between unwanted and mistimed pregnancies should be maintained. If the distinction is not maintained and unwanted and mistimed pregnancies are treated alike, there is the potential for gross overstatement of the public sector savings owing to prevention.
Program Eligibility Versus Participation
In the United States, far fewer women (or families) than are eligible for them actually participate in public support programs such as AFDC, Medicaid, WIC, and related programs. Yet the fiscal analyses of family planning either assume full participation among all eligible people or assume that a given proportion of eligible women participate irrespective of other socioeconomic characteristics. The first assumption is naive and clearly overstates the potential public sector savings that can be secured by prevention. The second assumption is less severe, but a more refined and informative estimate of public sector savings could be made by taking the socioeconomic characteristics of family planning clients into account.
Incomplete Accounting for Public Revenue Effects
When a working woman becomes pregnant unintentionally, she may experience at least a short period of withdrawal from the labor market; likewise, a nonworking woman may be discouraged from working as a result of the pregnancy. These labor market consequences result in lower tax revenues, a factor that many studies on fiscal consequences do not consider. The revenue implications extend beyond the period of labor market withdrawal or nonparticipation. When they are out of the labor market, women fail to add to their total labor market experience; this has implications for future earnings and tax payments. If a pregnancy to an adolescent interrupts schooling, human capital formation is also affected, again with lifetime implications for earnings and revenues. These effects have not been taken into account in any systematic fashion in the literature on fiscal consequences.
In spite of these caveats, which suggest that the public sector benefits of family planning funding may well have been exaggerated in some studies, the weight of the evidence presented by the several studies cited earlier (i.e., Levey et al., 1988; Forrest and Singh, 1990a,b; Vincent at al., 1991; Fitzgibbons, 1993; Olds et al., 1993; and Trussell et al., 1995) is that public funding of family planning services is likely to reduce net claims on public budgets. The magnitude of such reductions is much in doubt and will remain in doubt until rigorous research can be directed to this topic.
It is clear that much effort and many resources at the local, state, and national levels have been applied to programs to affect sexual behavior and contraceptive use, with much attention focused on young women. Although no formal evaluations of the large programs that help to finance or directly provide contraceptive services (such as Title X and Medicaid) have been completed, the support that these programs furnish undoubtedly helps to increase access to contraception, and thereby helps individuals avoid unintended pregnancy. Evaluations of the long-term effects of these programs are sorely needed, but they will be difficult to design.
Although there are hundreds of programs at the community level that in some way address sexual or contraceptive behavior related to unintended pregnancy, few have been carefully evaluated, and knowledge is therefore very limited about how local programs can reduce unintended pregnancy. Those that have been evaluated illustrate several cross-cutting themes:
- because most of the evaluated programs target adolescents, especially adolescent girls, knowledge about how to reach adult women or men is exceedingly limited;
- there is insufficient evidence to determine whether abstinence-only programs have been effective in increasing the age at first intercourse;
- sexuality education programs that provide information on both abstinence and contraceptive use neither encourage the onset of sexual intercourse nor increase the frequency of intercourse among adolescents; in fact, programs that provide both messages appear to be effective in delaying the onset of sexual intercourse and encouraging contraceptive use, especially among younger adolescents;
- even though most of the evaluated programs encourage contraceptive use in some way, there is a notable reluctance to provide program participants with contraceptive methods themselves or to help participants gain access to contraceptive services at some other site;
- about half of the evaluated programs attempting to reduce rapid repeat pregnancy, especially among adolescents, have been successful; and
- little is known from the evaluated programs about how to influence sexual behavior or contraceptive use by changing the surrounding socioeconomic or cultural environment.
Finally, the weight of the evidence is that public funding of family planning services is likely to reduce net claims on public budgets. The magnitude of such reductions is much in doubt, and will remain in doubt until rigorous research can be directed to this topic.
The Alan Guttmacher Institute. 11 Million Teenagers: What Can Be Done About the Epidemic of Adolescent Pregnancies in the United States? New York, NY: The Alan Guttmacher Institute; 1976.
Allen JP, Philliber S, Hoggson N. School-based prevention of teen-age pregnancy and school dropout: Process evaluation of the national replication of the Teen Outreach Program. Am J Commun Psychol. 1990;18:505–524.
Anderson JE, Cope LG. The impact of family planning program activity on fertility. Fam Plann Perspect. 1987;19:152–157.
Barth RP, Leland N, Kirby D, Fetro JV. Enhancing social and cognitive skills. In Preventing Adolescent Pregnancy: Model Programs and Evaluations. Miller BC, Card JJ, Paikoff RL, Peterson JL, eds. Newbury Park, CA: Sage Publications; 1992.
Burt MR. Estimating the public costs of teenage childbearing. Fam Plann Perspect. 1986;18:221–226.
Burt MR, Aron LY, Schack LR. Family planning clinics: Current status and recent changes in services, clients, staffing, and income sources. In Publicly Supported Family Planning in the United States. Washington, DC: The Urban Institute and Child Trends, Inc.; 1994.
The Center for Health Training. Male involvement in family planning: A bibliography of project descriptions and resources. Seattle, WA: The Center for Health Training; February 1988.
Christopher FS, Roosa MW. An evaluation of an adolescent pregnancy prevention programs: Is "just say no" enough? Fam Relat. 1990;39:68–72.
Corman H, Grossman M. Determinants of neonatal mortality rates in the US. J Health Econ. 1985;4:213–236.
Cutright P, Jaffe FS. Family planning program effects on the fertility of low-income US women. Fam Plann Perspect. 1976;8:100–110.
Danielson R, Marcy S, Plunkett A, Wiest W, Greenlick MR. Reproductive health counseling for young men: What does it do? Fam Plann Perspect. 1990;22:115–121.
Danielson R, McNally K, Swanson J, Plunkett A, Klausmeier W. Title X and family planning services for men. Fam Plann Perspect. 1988;20:234–237.
Donovan P. Family planning clinics: Facing higher costs and sicker patients. Fam Plann Perspect. 1991;23:198–203.
Dryfoos JG. Full-Service Schools: A Revolution in Health and Social Services for Children, Youth, and Families. San Francisco, CA: Jossey-Bass Publishers; 1994.
Dryfoos JG. School- and community-based pregnancy prevention programs. Adolesc Med. 1992;3:241–255.
Edwards L, Steinmann M, Hakanson E. Adolescent pregnancy prevention services in high school clinics. Fam Plann Perspect. 1980;12:6–15.
Edwards SR. The role of men in contraceptive decision-making: Current knowledge and future implications. Fam Plan Perspect. 1994;26:77–82.
Eisen M, Zellman GL. A health beliefs field experiment. In Preventing Adolescent Pregnancy: Model Programs and Evaluations. Miller BC, Card JJ, Paikoff RL, Peterson JL, eds. Newbury Park, CA: Sage Publications; 1992.
Eisen M, Zellman GL, McAlister AL. Evaluating the impact of a theory-based sexuality and contraceptive education program. Fam Plann Perspect. 1990;22:261–271.
Fitzgibbons E. Benefit: cost analysis of family planning in Washington State. Unpublished Master's thesis. University of Washington; 1993.
Forrest JD, Singh S. The impact of public-sector expenditures for contraceptive services in California. Fam Plann Perspect. 1990a;22:161–168.
Forrest JD, Singh S. Public-sector savings resulting from expenditures for contraceptive services. Fam Plann Perspect. 1990b;22:6–15.
Gilchrist LD, Schinke SP. Coping with contraception: Cognitive and behavioral methods with adolescents. Cognit Ther Res. 1983;7:379–388.
Girls Incorporated. Truth, trust and technology: New research on preventing adolescent pregnancy. Indianapolis IN; Girls Incorporated; October 1991.
Gold R, Daley D. Public funding of contraceptive, sterilization, and abortion services, fiscal year 1990. Fam Plann Perspect. 1991;23:204–211.
Gold R, Macias J. Public funding of contraceptive, sterilization, and abortion services, fiscal year 1985. Fam Plann Perspect. 1986;18:259–264.
Grossman M, Jacobowitz S. Variations in infant mortality rates among counties of the United States: The roles of public policies and programs. Demography. 1981;18:695–713.
Grunseit A, Kippax S. Effects of Sex Education on Young People's Sexual Behavior. World Health Organization. No date.
Hershey A, Rangarajan A. Implementing employment and training services for teenage parents. Princeton, NJ: Mathematica Policy Research, Inc.; 1993.
Howard M, McCabe JB. An information and skills approach for younger teens. In Preventing Adolescent Pregnancy: Model Programs and Evaluations. Miller BC, Card JJ, Paikoff RL, Peterson JL, eds. Newbury Park, CA: Sage Publications; 1992.
Howard M, McCabe JB. Helping teenagers postpone sexual involvement. Fam Plann Perspect. 1990;22:21–26.
Institute of Medicine. Developing New Contraceptives: Obstacles and Opportunities. Washington, DC: National Academy Press; 1990.
Institute of Medicine. Confronting AIDS: Update 1988. Washington, DC: National Academy Press; 1988.
Jorgensen SR. Project Taking Charge: An evaluation of an adolescent pregnancy prevention program. Fam Relat. 1991;40:373–380.
Jorgensen SR, Potts V, Camp B. Project Taking Charge: Six-month follow-up of a pregnancy prevention program for early adolescents. Family Relations. 1993;42:401–406.
Joyce TJ, Grossman M. Pregnancy wantedness and the early initiation of prenatal care. Demography. 1990;27:1–17.
Kantner JF, Zelnik M. Sexual experience of young unmarried women in the United States. Fam Plann Perspect. 1972;4:9–18.
Kantor LM. Scared chaste? Fear-based education curricula. SIECUS Report. New York, NY: Sex Information and Education Council of the US; 1992/1993;2:1–18.
Kirby D. School-based programs to reduce sexual risk-taking behaviors. J School Health. 1992;62:280–287.
Kirby D. Sexuality Education: An Evaluation of Programs and Their Effects. Santa Cruz, CA: Network Publications; 1984.
Kirby D, Barth RP, Leland N, Fetro JV. Reducing the risk: Impact of a new curriculum on sexual risk-taking. Fam Plann Perspect. 1991;23:253–263.
Kirby D, Harvey PD, Claussenius D, Novar M. A direct mailing to teenage males about condom use: Its impact on knowledge, attitudes and sexual behavior. Fam Plann Perspect. 1989;21:12–18.
Kirby D, Resnick MD, Downes B, et al. The effects of school-based health clinics in St. Paul on school-wide birthrates. Fam Plann Perspect. 1993;25:12–16.
Kirby D, Short L, Collins J, Rugg D, Kolbe L, Howard M, Miller B, Sonenstein F, Zabin LS. School-based programs to reduce sexual risk behaviors: A review of effectiveness. Public Health Rep. 1994;109:339–360.
Kirby D, Waszak C, Ziegler J. Six school-based clinics: Their reproductive health services and impact on sexual behavior. Fam Plann Perspect. 1991;23:6–16.
Klerman L. Programs for pregnant adolescent and young parents: Their development and assessment. In Teenage Parents and Their Offspring. Scott KG, Field T, Robertson E, eds. New York, NY: Grune and Stratton; 1981.
Klerman LV, Horwitz SM. Reducing the adverse consequences of adolescent pregnancy and parenting: The role of service programs. Adolesc Med. 1992;3:299–316.
Koo HP, Dunteman GH, George C, Green Y, Vincent M. Reducing adolescent pregnancy through a school- and community-based intervention: Denmark, South Carolina, revisited. Fam Plann Perspect. 1994;26:206–211, 217.
Ku L. Financing of family planning services. In Publicly Supported Family Planning in the United States. Washington, DC: The Urban Institute and Child Trends, Inc.; 1993.
Lee P. Failing to prevent unintended pregnancy is costly. Am J Public Health. Forthcoming.
Levey L, Nyman J, Haugaard J. A benefit-cost analysis of family planning services in Iowa. Eval Health Prof. 1988;11:403–424.
Manpower Demonstration Research Corporation. New Chance: A new initiative for adolescent mothers and their children. New York, NY: Manpower Demonstration Research Corporation; April 1993.
Maynard R, ed. Building self-sufficiency among welfare-dependent teenage parents: Lessons from the Teenage Parent Demonstration. Princeton, NJ: Mathematica Policy Research; June 1993.
Maynard R, Rangarajan A. Contraceptive use and repeat pregnancies among welfare-dependent teenage mothers. Fam Plann Perspect. 1994;26:198–205.
Meier K, McFarlane D. State family planning and abortion expenditures: Their effect on public health. Am J Public Health. 1994;84:1468–1472.
Miller BC, Dyk PH. Community of Caring effects of adolescent mothers: A program evaluation case study. Fam Relat. 1991;40:386–395.
Miller BC, Norton MC, Jenson GO, Lee TR, Christopherson C, King PK. Impact evaluation of Facts and Feelings: A home-based video sex education curriculum. Fam Relat. 1993;42:392–400.
Moore KA, Blumenthal C, Sugland BW, Hyatt B, Snyder NO, Morrison DR. State variation in rates of adolescent pregnancy and childbearing. Washington, DC: Child Trends, Inc.; 1994.
National Research Council. Losing Generations: Adolescents in High-Risk Settings. Washington, DC: National Academy Press; 1993.
National Research Council. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Vol. I. Washington, DC: National Academy Press; 1987.
Nicholson HJ, Postrado LT. A comprehensive age-phased approach: Girls Incorporated. In Preventing Adolescent Pregnancy: Model Programs and Evaluations. Miller BC, Card JJ, Paikoff RL, Peterson JL, eds. Newbury Park, CA: Sage Publications; 1992.
Olds D, Henderson C, Tatelbaum R, Chamberlin R. Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics . 1986;78:65–78.
Olds DL, Henderson CR, Phelps C, Kitzman H, Hanks C. Effects of prenatal and infancy nurse home visitation on government spending. Med Care. 1993;31:155–174.
Olds DL, Henderson CR, Tatelbaum R, Chamberlin R. Improving the life-course development of socially disadvantaged mothers: A randomized trial of nurse home visitation. Am J Public Health. 1988;78:1436–1455.
Olsen JA, Weed SE. Effects of family-planning programs for teenagers on adolescent birth and pregnancy rates. Fam Perspect. 1986;20:153–170.
O'Sullivan A, Jacobson B. A randomized trial of a health care program for first-time adolescent mothers and their infants. Nurs Res. 1992;41:210–215.
Philliber S, Allen JP. Life options and community service. In Preventing Adolescent Pregnancy: Model Programs and Evaluations. Miller BC, Card JJ, Paikoff RL, Peterson JL, eds. Newbury Park, CA: Sage Publications; 1992.
Polit DF. Effects of a comprehensive program for teenage parents: Five years after Project Redirection. Fam Plann Perspect. 1989;21:164–187.
Polit DF, Kahn JR. Project Redirection: Evaluation of a comprehensive program for disadvantaged teenage mothers. Fam Plann Perspect. 1985;17:150–155.
Polit DF, Quint JC, Riccio JA. The Challenge of Serving Teenage Mothers: Lessons from Project Redirection. New York, NY: Manpower Demonstration Research Corporation; October 1988.
Postrado LT, Nicholson HJ. Effectiveness in delaying the initiation of sexual intercourse of girls aged 12–14: Two components of the Girls Incorporated Preventing Adolescent Pregnancy Program. Youth Soc. 1992;23:356–379.
Quint J, Musick J, Ladner J. Lives of Promise, Lives of Pain. New York, NY: Manpower Demonstration Research Corporation; January 1994.
Quint JC, Fink BL, Rowser SL. Implementing a Comprehensive Program for Disadvantaged Young Mothers and Their Children. New York, NY: Manpower Demonstration Research Corporation; December 1991.
Quint JC, Polit DF, Bos H, Cave G. New Chance: Interim Findings on a Comprehensive Program for Disadvantaged Young Mothers and Their Children. New York, NY: Manpower Demonstration Research Corporation; September 1994.
Roosa MW, Christopher FS. A response to Thiel and McBride: Scientific criticism or obscurantism? Fam Relat. 1992;41:468–469.
Roosa MW, Christopher FS. Evaluation of an abstinence-only adolescent pregnancy prevention program: A replication. Fam Relat. 1990;39:363–367.
Ruch-Ross HS, Jones ED, Musick JS. Comparing outcomes in a statewide program for adolescent mothers with outcomes in a national sample. Fam Plann Perspect. 1992;24:66–71, 96.
Schinke SP, Blythe BJ, Gilchrist LD. Cognitive-behavioral prevention of adolescent pregnancy. J Couns Psychol. 1981;28:451–454.
Schinke SP, Gilchrist LD, Small RW. Preventing unwanted adolescent pregnancy: A cognitive-behavioral approach. Amer J Orthopsychiatry. 1979;49:81–88.
Seitz V, Apfel N. Effects of a school for pregnant students on the incidence of low-birth-weight deliveries. Child Develop. 1994;65:666–676.
Seitz V, Apfel NH. Adolescent mothers and repeated childbearing: Effects of a school-based intervention program. Amer J Orthopsychiatry. 1993;63:572–581.
Singh S. Adolescent pregnancy in the United States: An interstate analysis. Fam Plann Perspect. 1986;8:10–20.
Stahler GJ, DuCette JP. Evaluating adolescent pregnancy programs: Rethinking our priorities. Fam Plann Perspect. 1991;23:129–133.
Thiel KS, McBride D. Comments on an evaluation of an abstinence-only adolescent pregnancy prevention program. Fam Relat. 1992;41:465–467.
Torres A, Donovan P, Dittes N, Forrest JD. Public benefits and costs of government funding for abortion. Fam Plann Perspect. 1986;18:111–118.
Trussell J, Leveque JA, Koening JD et al. The economic value of contraception: A comparison of 15 methods. Am J Public Health. 1995;85:494–503.
Vincent ML, Clearie AF, Schluchter MD. Reducing adolescent pregnancy through school and community-based education. JAMA. 1987;257:3382–3386.
Vincent ML, Lepro S, Baker, Garvey D, Projected public sector savings in a teen pregnancy prevention project. J Health Educ. 1991;22:208–212.
Vinovskis MA. An ''Epidemic" of Adolescent Pregnancy? Some Historical and Policy Considerations. Oxford: Oxford University Press; 1988.
Walker G, Vilella-Velez F. Anatomy of a Demonstration: The Summer Training and Education Program (STEP) from Pilot through Replication and Postprogram Impacts. Philadelphia, PA: Public/Private Ventures; 1992.
Weed SE, Olsen JA. Effects of family-planning programs on teenage pregnancy—replication and extension. Fam Perspect. 1986;20:173–194.
Zabin LS, Hirsch MB. Evaluation of Pregnancy Prevention Programs in the School Context. Lexington, MA: Lexington Books; 1987.
Zabin LS, Hirsch MB, Smith EA, Strett R, Hardy JB. Evaluation of a pregnancy prevention program for urban teenagers . Fam Plann Perspect. 1986;18:119–126.
Zabin LS, Hirsch MB, Streett R, Emerson MR, Smith M, King TM. The Baltimore Pregnancy Prevention Program for Teenagers. I. How did it work? Fam Plann Perspect. 1988;20:182–192.