This report is about unintended pregnancy, a general term that includes pregnancies that a woman states were either mistimed or unwanted at the time of conception.1 Unintended pregnancy in the United States is an important and complex problem that has significant consequences for the health and well-being of all Americans.
The study that culminated in this report was shaped and influenced by a wide variety of both demographic and social phenomena. Some of these phenomena were evident at the outset, and others emerged only as the project progressed. In the former category were the numbers. Data published in the 1980s indicated that rates of unintended pregnancy in the United States were higher than those in several other industrialized countries (Jones et al., 1989). Then, in 1990, analyses from the 1988 National Survey of Family Growth showed that declines in births derived from unintended pregnancies during the 1970s had reversed in the 1980s, with particular increases noted among poor women (Williams and Pratt, 1990). These figures indicated that progress on one of the most basic measures of women's autonomy—determining whether and when to bear children—had eroded, a development that could only undermine efforts to improve women's capacity for self-determination and full participation in their communities. Moreover, the increases in the number of births derived from unintended pregnancies were not confined to adolescents, which suggested that the nation's continuing focus on teenage pregnancy might well be missing
a larger issue: that adults as well as teenagers have difficulty planning and preventing pregnancy.
Another major force stimulating the Institute of Medicine's initial interest in studying unintended pregnancy was a concern that too little attention had been given to the relationship of pregnancy intendedness to the health and well-being of children. Throughout the late 1980s and early 1990s, there was an appreciable amount of advocacy on behalf of children. Even in the face of limited budgets and competing demands, many states and the federal government found numerous ways to direct money and attention to children: expanding eligibility for Medicaid in order to finance health care for more low-income children and pregnant women; increasing authorizations for the popular Head Start program; and stimulating programs in virtually every state to address infant mortality and early childhood immunization, improve the quality of education, offer early intervention services for at-risk families, reach pregnant women with prenatal care, and use school settings in new ways to provide a wide variety of human services.
But the world of education, counseling, and care that supports careful contraceptive use—often called family planning—has been starkly absent from the "children's agenda" as articulated over the past 10 to 15 years. In fact, pregnancy prevention and family planning have generally been treated as marginal or controversial activities, rarely discussed in a broad, comprehensive way that recognizes the important role that fertility control plays in the lives of men and women, in child and family well-being, and in the overall tenor of communities.2 In particular, pregnancy planning has not been included as a central, routine component of human services, especially preventive health care and education; by contrast, a number of other countries have found many ways to incorporate family planning services into primary care, often as part of maternal and child health services. As evidence of this neglect, public investment in family planning services declined during the 1980s, perhaps by as much as a third. In particular, federal outlays for family planning through the Title X program (that portion of the Public Health Service Act that provides grants to various state and local entities to offer family planning services to low-income women and adolescents) dropped precipitously during the 1980s, although increased commitments from other public and private sources helped to fill a portion of the gap (Ku, 1993; Gold and Daley, 1991).
An additional influence on this project was the intense debate about health care reform during the 103rd Congress and the growth of managed care systems
throughout the nation. Both developments have revealed underlying disagreements about whether and how contraception should be financed and about the systems that should be in place to provide reproductive health services generally. As first the White House and then the Congress attempted to design a standard package of benefits that should be available to all insured Americans as part of health care reform, controversy arose over whether contraceptive services and supplies (as well as abortion) should be included and the extent to which copayments and deductibles should be applied to these and related services. And as managed care networks increasingly dominate health care financing in states and communities, new questions have arisen about the fate of the Title X program and other categorical grant programs now operating side-by-side with growing numbers of health maintenance organizations and other integrated systems. In some communities, categorical family planning programs have found ways to work smoothly with managed care networks, and in others, the relationship has been more difficult (Rosenbaum et al., 1994). Some have suggested that categorical family planning programs are no longer necessary in communities with broad insurance coverage; others claim that the need for such specialized, comprehensive services remains apparent, especially for low-income and adolescent women, many of whom are uninsured. This issue has taken on new importance given the increasing use of managed care networks by state Medicaid programs, which often have heavy caseloads of women in their childbearing years who need a wide variety of reproductive health services.
Intensifying discussions about welfare reform, and, in particular, the issue of childbearing by single women currently receiving cash assistance, also shaped the environment in which this project unfolded. Policymakers have suggested—and some states have actually legislated—that welfare payments not be increased if women bear additional children while on welfare, the notion being that welfare itself might provide an inappropriate incentive for childbearing and that job training and educational programs for mothers on welfare are hindered by repeated pregnancies.
One particularly interesting aspect of the welfare debate is its focus on both childbearing by women under age 20 as well as on nonmarital childbearing, two overlapping but distinct phenomena that are often treated as though they were one and the same. Data on births to adolescent women show that the birthrate in 1991 continued the rise that began in the latter years of the 1980s. Between 1986 and 1991, the rate of births to teens rose 24 percent, from 50 to 62 births per 1,000 females aged 15–19. This increase in the birthrate has occurred among both younger and older teens and in nearly all states (Moore, 1994). More recent data show a slight decline in the birthrate among teenagers between 1991 and 1992; even so, overall levels remain 21 percent higher than they were in 1986 (Moore, 1995). Births among unmarried women have also increased such that,
by 1991, nearly one-third of all births were to unmarried women.3 Although the rate of childbearing among unmarried women is higher among black than white women (DaVanzo and Rahman, 1993), much of the recent overall increase in childbearing among unmarried women has been fueled by a steep rise in births among unmarried white women (Ventura et al., 1994). These troubling data raise a critical, largely ignored question: To what extent are pregnancies among adolescent and unmarried women intended, especially those occurring among poor women? Are these pregnancies accidents? Or are they consciously planned and actively sought, derived from a clear desire to have a child, despite very young age, poverty, or the absence of marriage or even a committed partner (Dash, 1989)? Answers to these questions have obvious relevance to evolving welfare policy. If, for example, data suggest that most such pregnancies are unintended, it may be that finding ways to increase the use of contraception should be a major part of strategies to reduce welfare dependency. In various sections of this report, this connection between the welfare debate and unintended pregnancy is highlighted.
Another factor shaping the course of the project was the fact that men have largely been excluded from the research, programs, and policies designed to reduce unintended pregnancy in the United States. Although there have been scattered attempts around the nation to involve men in family planning services, for example, or to develop materials on contraception that are oriented to male concerns, much of this activity has been driven by efforts to control the spread of acquired immune deficiency syndrome (AIDS) and other sexually transmitted diseases (STDs), leaving pregnancy prevention largely a woman's concern. Despite the ostensible logic to this state of affairs (inasmuch as it is the female, not the male, who becomes pregnant), men obviously play a significant role in family formation. It became increasingly apparent to the committee over the course of this project that men must be involved in pregnancy prevention in a variety of ways beyond just encouraging condom use (Edwards, 1994). In the related area of childbirth, for example, men are now welcomed into what had for years been a process managed exclusively by women in labor and their doctors. Fathers now increasingly participate in classes that prepare couples for
Despite recent increases, the U.S. level of nonmarital childbearing remains significantly lower than that found in many other countries, including several European ones (United Nations, 1991). At the same time, it is important to point out that in these European countries, especially the Scandinavian ones, up to three-quarters of these nonmarital births are to couples who are cohabitating, which may provide a family context for children that is similar to that provided by marital unions. By contrast, much of the nonmarital childbearing in the United States is not accompanied by cohabitation (Bumpass and Sweet, 1989), thereby providing less favorable family contexts for children, as discussed in more detail in Chapter 3.
labor and delivery, and they are often present in delivery rooms also. This development in childbirth highlights the interest of men in family formation, and lends added weight to the notion that men could be more deeply involved in pregnancy prevention and planning as well.
Federal and state legislation designed to strengthen child support enforcement and paternity establishment also focuses attention on males in that it provides new incentives for unmarried men in particular to take greater responsibility for preventing unintended pregnancy. The Family Support Act of 1988 requires states to establish paternity for all children born outside marriage and to require all unmarried fathers to pay child support until their child reaches 18 years of age; although it is too soon to gauge the impact of this law definitively, early reports are that there has been an increase in the percentage of children born outside of marriage who have paternity established and who have a child support award (Hanson et al., 1995). Current welfare reform proposals put even greater emphasis on establishing paternity. Whereas in the past an unmarried father could, in essence, walk away from a child born outside of marriage if he chose to do so, today both the law and public opinion make this a less available option.
The human immunodeficiency virus (HIV) and AIDS epidemic was also an important part of this project's genesis. Data now suggest that the incidence of HIV infection among women is accelerating at an alarming rate. Moreover, the epidemic has apparently increased the willingness of the public and some elected officials to address more candidly such issues as high-risk sexual behavior and at least one form of contraception—condoms. Topics that were once expressly forbidden in the electronic media are now common fare on talk shows and news specials, signaling that new opportunities have opened for communication and education. The present study was organized in part to take advantage of this new willingness to address sexual behavior, in the hope that pregnancy prevention, too, could be approached more directly.
Finally, it is important to acknowledge two particular issues that shaped this study: the controversies over abstinence-based education and over abortion. During the 1980s, there was a movement at the federal level, and among some communities as well, to promote abstinence instead of contraception as the major means of preventing pregnancies (as well as AIDS and STDs) among unmarried adolescents. This argument spawned impassioned debates about whether abstinence was an outmoded concept in the late twentieth century that ignored the realities of adolescent sexual activity and about whether discussing contraception with teenagers gave tacit approval to their sexual activity, or perhaps even encouraged it. Disagreements were especially intense over whether school-based sex education for adolescents should stress abstinence only, or should combine messages about abstinence with material on contraception as well. Although some federal health officials took the former position, other people, especially those in the family planning field, took the latter view,
thereby often finding themselves at odds with federal policy leaders. The intensity of the debate had the unfortunate effect of polarizing many groups who share a common interest in reducing adolescent pregnancy. Thus, the time seemed right for a review of the knowledge base regarding the causes, consequences, and prevention of unintended pregnancy, including the effectiveness of abstinence-based education.
Abortion is perhaps the most divisive issue related to unintended pregnancy. As any observer of the American scene over the last 20 years could readily discern, the abortion controversy has dominated discussions of reproductive health and has led to painful divisions across many ideological, political, and religious lines. The heated debate over the acceptability of abortion itself has diverted attention from many other important and closely related issues, such as finding ways to encourage couples to prevent both unintended pregnancy and STDs simultaneously or learning how best to offer contraceptive services in communities whose health care systems are changing rapidly. Put another way, in arguing about how to resolve problem pregnancies, less attention has been given to preventing such pregnancies in the first place. The controversy has also obscured the very important differences between abortion and contraception and has led, in some instances, to contraception being treated as gingerly as abortion. Among other results, this unfortunate confusion between abortion and contraception has shifted attention away from the proposition that better use of contraception is a highly effective way to reduce the incidence of abortion.
This is not to suggest, however, that unintended pregnancy in the United States would have been eliminated by now were it not for the abstinence and abortion controversies. In fact, only 40 years ago the notion of carefully planned, controlled fertility in this country seemed an elusive, futuristic goal with little reasonable chance of actually occurring. Many of the most effective reversible methods of contraception—for example, intrauterine devices and oral contraceptives—have only been available since the early 1960s and have just recently been joined by hormonal implants and injections. Moreover, it was only in 1965 that it was clearly declared legal in the United States for married couples to secure and use contraception (Griswold v. Connecticut); similar protection was not granted to unmarried individuals until 1972 (Eisenstadt v. Baird). Thus, modern patterns of contraceptive use in the United States—and even the legality of many methods—are recent developments. It would be unrealistic to expect that in the mid-1990s contraception would be used universally and with no errors, failures, or missteps along the way (additional historical perspectives are presented in Appendix B). The use of many forms of reversible contraception carefully and successfully can be a complicated undertaking that requires a unique convergence of several factors including a supportive social environment, peer and personal values consistent with diligent contraceptive use, affordable and accessible methods of contraception, and partner agreement and, often,
active partner cooperation. The continuing occurrence of unintended pregnancy in the United States suggests that it may well take many years to realize the full promise of modern contraception and fertility control.
Focus of this Report
Within this broad context, the Institute of Medicine's Committee on Unintended Pregnancy was established to explore the relationship of unintended pregnancy in the United States to the health and well-being of children and families and to make recommendations for policy, practice, and research. In so doing, the committee was asked to:
- define what is meant by unintended pregnancy and related terms used in the relevant data and research;
- summarize evidence regarding the effects that unintended pregnancy (e.g., both mistimed and unwanted pregnancy) has on the health and well-being of children, youth, and adults (to include commentary on the role of abortion in resolving unintended pregnancies);
- analyze patterns of and trends in unintended pregnancy, noting the populations in whom unintended pregnancy is concentrated;
- outline the various reasons that might help to explain the observed patterns;
- 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; and
- make conclusions and recommendations for policy, practice, and research based on the data assembled and reviewed.
The audience for this activity was defined to be policymakers at the federal, state, and local levels; administrators of relevant health and social service programs, including those who are active in the fields of child welfare, family planning, and reproductive health generally; opinion leaders in foundations, the business community, and the media; and scientists in a position to act on the committee's research recommendations.
Study Methods and Report Organization
In meeting its charge, the committee and staff used several methods to gather the needed information. They reviewed published data and analyses; studied numerous commissioned and contributed papers on a variety of topics about which the group felt it needed more information (Appendix A); talked
informally, during committee meetings and at other times, with experts on the various topics it was studying; requested one original piece of analytic work by The Alan Guttmacher Institute using the 1988 National Maternal and Infant Health Survey; conducted an analysis of what the childbearing population in the United States would look like if unintended pregnancies were eliminated; and held five meetings of the full committee over a 14-month period (from September 1993 through October 1994). Both committee members and staff participated in drafting the report. In addition, a careful effort was made to learn about programs in place around the country that address unintended pregnancy; the methods used in that portion of the committee's work are described in more detail in Chapter 8.
Following this introductory chapter, Chapter 2 presents data on rates of and trends in unintended pregnancy and on the populations in which unintended pregnancy is concentrated. Chapter 3 summarizes data on the health and social consequences of unintended pregnancy from the perspective of children and adults and discusses abortion as a major consequence of unintended pregnancy. It also addresses the socioeconomic consequences for children and their mothers of both adolescent parenthood and childbearing among unmarried women, because unintended pregnancy is particularly common among women who are teenaged, unmarried, or both.
Subsequent chapters address the fundamental question that unintended pregnancy poses: Why do Americans report such high levels of unintended pregnancy, even in the presence of numerous contraceptive methods? The most immediate and obvious answer, of course, is contraceptive nonuse, misuse, or failure. Thus, Chapter 4 is devoted to reviewing patterns of contraceptive use as they relate to unintended pregnancy.
The report then moves on to a discussion of factors that influence contraceptive use. Information on these factors—often called determinants—is scattered and often confusing and is peppered with as much opinion as data. On one point, however, there is clear consensus: many, many factors affect the use of contraception and thus unintended pregnancy. The committee found it helpful to group these factors into three sets: (1) knowledge about contraception, unintended pregnancy, and human reproduction in general, as well as access to contraception itself; (2) personal motivation, attitudes, beliefs, and feelings related to contraceptive use; and (3) the overall socioeconomic and cultural environment.
Chapter 5 addresses the first set of factors, asking whether unintended pregnancy may be explained in part by insufficient knowledge about contraception and related topics, as well as by limited access to the most effective methods of birth control. In the discussion of knowledge about contraception, schools and the media are highlighted; in the area of access to contraception, the emphasis is on financial and other barriers that limit an individual's ability to secure various methods of birth control.
Chapter 6 discusses the second set of factors affecting unintended pregnancy—the complex web of individual motivation, feeling, attitudes, and beliefs that shape contraceptive use as well as sexual activity. This section contains some of the most provocative and important material in the report, inasmuch as it touches on the more emotional, sometimes irrational, dimensions of human behavior and male–female relationships that are so closely connected to the occurrence of any pregnancy, intended or not.
Chapter 7 addresses numerous social forces that influence fertility and the effective use of contraception: political and religious diversity, views about sexuality, historical and ongoing racism, economic factors, cultural and ethnic diversity, gender bias, the far-reaching effects of the antiabortion movement, and the pervasive influence of violence in American life. The broad scope of this chapter is highly consistent with deliberations at the recent United Nations International Conference on Population and Development in Cairo, which addressed both men and women in fertility decisions, the integral part that socioeconomic and cultural environments play in reproductive behavior, the pervasive influence of gender bias and other women's issues in population trends, and the importance of addressing human sexuality as part of reproductive health services and policies (United Nations, 1994).
Chapter 8 reviews several pregnancy prevention programs to determine whether there is a strong knowledge base at the local level about how to reduce unintended pregnancy. Although there are literally hundreds of programs recently completed or currently under way in the United States that in some way address unintended pregnancy, this chapter focuses squarely on the few that have been evaluated. The chapter also comments on both Medicaid and the Title X program because they are major sources of public funding for family planning services nationwide.
The final chapter, Chapter 9, presents the committee's conclusions and recommendations. These are addressed to public policy, provision of services, and, in particular, research.
As the foregoing overview suggests, this report is confined to an analysis of unintended pregnancy in the United States. Nonetheless, the report does occasionally draw on international data in order to put certain U.S. numbers into perspective, to consider how other countries may have handled particular problems, or to ponder the feasibility of selected remedies.
Bumpass L, Sweet J. Children's experience in single-parent families: Implications of cohabitation and marital transitions. Fam Plann Perspect. 1989; 21:256–260.
Carnegie Corporation of New York. Starting Points: Meeting the Needs of Our Youngest Children. New York, NY; 1994.
Dash L. When Children Want Children. New York, NY: Penguin Books; 1989.
DaVanzo J, Rahman MO. American Families: Trends and Policy Issues. Santa Monica, CA: RAND; 1993.
Edwards SR. The role of men in contraceptive decision-making: Current knowledge and future implications. Fam Plann Perspect. 1994;26:77–82.
Gold RB, Daley D. Public funding of contraceptive, sterilization and abortion services, fiscal year 1990. Fam Plann Perspect. 1991;23:204–211.
Hanson T, McLanahan S, Garfinckel I, Miller C. Trends in child support outcome. Unpublished manuscript. Princeton University. 1995.
Jones EF, Forrest JD, Henshaw SK, Silverman J, Torres A. Pregnancy, Contraception and Family Planning Services in Industrialized Countries. New Haven, CT: Yale University Press; 1989.
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.
March of Dimes Birth Defects Foundation. Towards Improving the Outcome of Pregnancy: The 90s and Beyond. New York, NY; 1993.
Moore KA. Facts at a Glance. Washington, DC: Child Trends, Inc.; February 1995.
Moore KA. Facts at a Glance. Washington, DC: Child Trends, Inc.; January 1994
Rosenbaum S, Shin P, Mauskopf A, Funk K, Stern G, Zuvekas A. Beyond the Freedom to Choose: Medicaid, Managed Care and Family Planning. Washington, DC: Center for Health Policy Research, The George Washington University; 1994.
United Nations. Program of Action: Report from the International Conference on Population and Development. New York, NY; 1994.
United Nations. The World's Women 1970–1990: Trends and Statistics. New York, NY: United Nations; 1991.
Ventura SJ, Martin JA, Taffel SM, Matthews TJ, Clarke SC. Advance Report of Final Natality Statistics, 1992. Mon Vital Stat Rep. 1994;43(5 Suppl).
Williams LB, Pratt WP. Wanted and unwanted childbearing in the United States: 1973–1988. Advance Data from Vital and Health Statistics, no. 189. Hyattsville, MD: National Center for Health Statistics; 1990.