Basic Requirements: Contraceptive Knowledge and Access
The patterns of contraceptive use, misuse, and nonuse described in the previous chapter are troubling because a common result is unintended pregnancy. These patterns are also quite puzzling; with so many different contraceptive devices in existence, some widely available, even in drugstores, what is the explanation for inadequate contraceptive vigilance?
This chapter reviews two factors that might help to explain these observed patterns. The first is that inadequate use of contraception may be traceable in part to insufficient knowledge about methods of birth control and related issues of human reproduction, as well as to difficulty in mastering the skills that many reversible methods of contraception require. This section also considers the adequacy of school-based education and information about contraception.
The second issue considered is that access to contraceptive services and supplies—particularly for the more effective methods—may be limited. Later chapters discuss various personal and interpersonal factors that affect contraceptive use and therefore unintended pregnancy (Chapter 6), as well as the broader sociocultural and economic environments in which decisions about contraception and pregnancy are made (Chapter 7).
This focus on knowledge, skills, and access is not meant to obscure another possible explanation for unintended pregnancy, which is the relatively limited and often unsatisfactory array of contraceptive methods available to men and women in the United States. Experts in contraception and family planning, as well as men and women themselves, have long noted that the existing array of methods is often ill suited to the varying needs of couples and individuals over time, and that some methods are too difficult or unpleasant to use consistently,
while others are too expensive or unsatisfactory in some other way. This underlying discontent with current contraceptive technology is at the heart of repeated calls for expanded research to develop new forms of contraception (Chapter 9).
It is also important to emphasize here that the committee considers knowledge about methods of birth control, as well as access to them, to be basic requirements for effective contraceptive use. This view is consistent with observations about such other preventive interventions as prenatal care and immunizations, where the point has been made that both knowledge and access are necessary preconditions to use (Institute of Medicine, 1994, 1988). However, as subsequent material suggests, these basic elements, on their own, may not be enough to produce careful and consistent use of contraception; they are necessary but may not always be sufficient to prevent unintended pregnancy. Put another way, it is unreasonable to expect widespread, careful use of contraception in the absence of basic knowledge and access to services, but this does not mean that when such pieces are in place good contraceptive use is guaranteed. This perspective is developed in more detail in Chapter 6.
Knowledge, Skills, and School-Based Education
One of the explanations most often given for unintended pregnancy is that men and women, especially those who are teenagers, are poorly informed about contraception and related topics in reproductive health. Accordingly, this section considers that explanation and also addresses the skills needed to use many reversible methods. The section concludes with a discussion of school-based education and information about contraception.
Individuals learn about contraceptive methods, including their risks and benefits, as well as how to use them, from a wide variety of sources: friends and family, the electronic and print media, health professionals and the educational materials that they distribute, such institutions as schools and colleges, and numerous community resources. Unfortunately, few data are available to assess carefully the content and quality of the information provided in each of these settings. There are data about school-based sex education programs, summarized later in this chapter, but little on the content and quality of information available through the adolescent grapevine, for example. Few studies have addressed the education that parents offer their children about contraception, although some studies suggest that parents often do not discuss contraception with their children and that, in any event, such communication may not exert much of an effect on
the child's subsequent use of contraception (Tanfer, 1994). Moreover, the information about media content—especially television—pertains more to its overall sexual content than to its information about contraception (Chapter 7).
There is, however, clear evidence that many Americans are misinformed about the risks and benefits of particular contraceptive methods—exaggerating the former and underestimating the latter, especially in the case of oral contraceptives. For example, a 1993 Gallup poll found that more than half of American women believe there are ''substantial risks" (mainly cancer) involved in using the birth control pill, and 4 in 10 erroneously believe that the health risks of taking oral contraceptives are greater than those of childbearing (Gallup Organization, 1994). The widespread lack of knowledge among both providers and potential users regarding emergency contraception1 is another indication that many Americans lack basic information about all available means of contraception (Grossman and Grossman, 1994; Trussell and Stewart, 1992).
Numerous smaller studies confirm this general picture. Balassone (1989), for example, conducted a prospective study of 76 sexually active teenaged women securing oral contraceptives at several private family planning clinics, and found that, in general, the young women underestimated the chances of pregnancy in the absence of contraception, and had inaccurate knowledge regarding the effectiveness of various contraceptive methods. In 1991, 247 women (mean age of 30.2 years) receiving care at a university health center were queried about their views of the benefits and risks of the pill. Almost half believed that oral contraceptives carry substantial risks, cancer in particular. Large percentages—between 80 and 95 percent—were unaware of the health benefits of oral contraceptives other than pregnancy prevention (e.g., the protective effect against benign breast disease, the reduced risk of both ovarian and endometrial cancer, and the lowered risk of pelvic inflammatory disease) (Peipert and Gutmann, 1993). Similarly, Lowe and Radius (1987) reported that "dangerous misconceptions" prevailed among unmarried college students with regard to knowledge of anatomy, physiology, and the appropriate use of effective contraception. And in their study sample of low-income black adolescents, Poland and Beane (1980) reported that teenagers articulated the common mythology that IUDs, for example, can "get lost in the body," and that
if pregnancy occurs with an IUD in place, the baby will be born with the device in it somewhere.
One reason that Americans are misinformed about contraception generally may be that the electronic media tend to report more of the bad news than the good news about various methods. Some data support this widely held view—especially the notion that the protective health benefits offered by various contraceptives are often underpublicized compared with the modest risks (Peipert and Gutmann, 1993; Adams Hillard, 1992). Clinic personnel report, for example, that adverse media coverage of Norplant has led to requests for removal of the implant, even among women who were experiencing no problems (Herman, 1994). Additional material is presented in Chapter 7 suggesting that although the electronic media present copious amounts of sexually enticing material, they rarely air complementary information on how to prevent such consequences of sexual activity as unintended pregnancy or sexually transmitted diseases (STDs).
Numerous studies of adolescents have clearly shown that many also have very limited and often faulty information about when fertility begins, the timing of fertility within the menstrual cycle, and the probability of conception (see, for example, Clark et al., 1984; Cvetkovich and Grote, 1983; Oskamp and Mindick, 1983; Foreit and Foreit, 1981). A common reason given by adolescents for nonuse of contraception is that on a given occasion, the risk of pregnancy was judged to be low because of the "time of month." Yet research has confirmed that a substantial proportion of those who cite time of month as the reason for foregoing contraception could not correctly identify the period of greatest risk (Tanfer, 1994).
It is not just adolescents who have incorrect information about human sexuality and contraception, however; adults may as well. When the Annie E. Casey Foundation began working in the early 1990s with groups of parents to improve their communication with young people about sex, contraception, and related topics to reduce teenage pregnancy (as part of the foundation's Plain Talk initiative), program leaders quickly learned that the parents themselves had major gaps in their knowledge about the topics at hand and that they needed help not only in communicating about sexual issues, but also in mastering basic information (S.L. Edwards, pers. com., 1994).
Polling data on STDs also suggest a widespread lack of accurate information regarding sexual health. In 1993, the Campaign for Women's Health and the American Medical Women's Association sponsored a poll (via telephone interviews with 1,000 randomly selected women aged 18–60) to learn more about American women's knowledge about STDs generally. Key findings included the following: 84 percent said they are not worried about contracting an STD (including 78 percent of those with multiple partners); 66 percent knew virtually nothing about STDs other than HIV and AIDS; only 1 in 10 reported being "very knowledgeable" about STDs; only 11 percent knew that many STDs
can be more harmful to women's health than to men's; and 53 percent viewed STDs as a "dirty" disease that represents either shame or punishment (Campaign for Women's Health and American Medical Women's Association, 1994).
Such misinformation can lead to poor contraceptive use and therefore unintended pregnancy. A study in the mid-1980s, for example, probed reasons that sexually active teenage women delay making a first visit to a family planning clinic. Information was collected from more than 400 sexually active young women under age 19 attending family planning clinics and from about 400 sexually active female students at two junior and two senior high schools. Across all groups, one of the most commonly cited reasons for delay in attending a family planning clinic was that contraception is "dangerous." For example, among those who had never gone to a clinic at all, 19 percent cited this reason as the most important factor explaining their delay, and an additional 45 percent listed it as a "contributing" factor (Zabin et al., 1991). Similarly, in the Balassone (1989) study mentioned earlier, the subjects least likely to continue using oral contraceptives at 3 months' follow-up were those who believed that there were appreciable health-related problems associated with using oral contraceptives, felt that their risk of pregnancy was less than that of their peers, and had poor problem-solving skills. Chapter 6 presents more detailed information on the fears, attitudes, and feelings that can influence contraceptive use.
In sum, there is significant misinformation among both adults and adolescents about the risks and benefits of contraception. This lack of knowledge can limit efforts to obtain contraception and continue using it, thereby increasing the risk of unintended pregnancy.
Knowledge about contraception is particularly important because many reversible methods of contraception require considerable skill for proper use. Patient package inserts, education and counseling sessions at many birth control clinics, and various popular books attempt to educate users about the nitty-gritty of how to use specific methods and how to manage problems that are commonly encountered. But practitioners in the field, such as workers in family planning clinics, report that there is great variation in the abilities of clients to use methods properly and that there may not be adequate appreciation of the difficulty faced in mastering the mechanics of contraception (Quint et al., 1994). To use a diaphragm correctly, for example, one must know at a minimum where to go to get the method, how to insert the device properly and to check its position, how much spermicide to apply, how many hours after intercourse to remove it, how to insert additional spermicide into the vagina if repeated intercourse will occur while the diaphragm is still in place, and how to check for
holes or tears in the device. Moreover, this information must be used properly each time that the diaphragm is employed, and the user must be willing to forego intercourse or use alternative methods of contraception if the diaphragm is unavailable for some reason. An equally long list of complexities is attached to oral contraceptive use (Oakley, 1994), as noted in Chapter 4. Rarely do contraceptive counselors have the time to cover all of these issues or to reinforce key messages through follow-up, which is one of the reasons that the longer-acting methods (such as hormonal implants and injections) continue to attract interest. Reflecting these difficulties, Adams Hillard (1992) reports that adolescents miss taking an average of three pills monthly and between 20 and 30 percent of all users of oral contraceptives miss a pill every month.
The complexity of the contraceptive task may also be one of the reasons that some studies have shown a link between education, cognitive functioning, and unintended pregnancy—specifically, that contraceptive use increases with education. With more years of schooling, a woman may be better equipped to understand the risks and benefits of becoming pregnant, to make plans to reduce that risk, and then to execute those plans. Consistent with this view, in a national sample of never-married women in their 20s at risk of pregnancy, when the effects of other social and demographic variables were controlled, education was found to be associated not only with better contraceptive use but also with the choice of more effective methods (Tanfer et al., 1992). Among urban female adolescents attending family planning clinics, the stage of cognitive development was found to be the best predictor of contraceptive decision-making (Sachs, 1985). Several studies have also shown that better educated or high-income women who use less effective methods use them more effectively than less educated or low-income women who use the same methods (Jones and Forrest, 1992, 1989; Grady et al., 1986, 1983; Schirm et al., 1982).
School-Based Education and Information
One source of contraceptive information and education that has been studied more thoroughly than others is schools. Most school-based sex education programs can be categorized into one of four types: (1) those that try to increase knowledge about reproductive health and especially about all methods of pregnancy prevention including abstinence, and emphasize the risk and consequences of pregnancy; (2) those that do the same and add material on "values clarification" and skills in communicating and decision-making; (3) those that advocate abstinence but do not discuss contraception; and (4) those that accompany comprehensive education in reproductive health with clinical services including family planning care. In both this section of the report and elsewhere (Chapter 8 especially), various aspects of these approaches are discussed.
Public opinion and public policy both support a strong role for schools in educating young people about human sexuality, whatever the controversies in some communities. The American College of Obstetricians and Gynecologists, for example, commissioned the Gallup Organization to conduct a study of public knowledge of and attitudes toward contraception. This 1985 study of 1,036 women and 520 men aged 18 and over showed that approximately 90 percent of the adult population wanted sex education to be taught in schools. Fifty-four percent of women and 47 percent of men wanted it to start in elementary school; 81 percent of women and 74 percent of men wanted sex education to start before high school (American College of Obstetricians and Gynecologists, 1985). Similarly, the Sexuality Information and Education Council of the United States reports that there is strong public support for sexuality education, including explicit instruction about contraception and STD prevention. More than 8 in 10 adults support teaching about sexuality in the public schools; more than 9 in 10 want AIDS education for their children. Seventy-seven percent think that courses for 12-year-olds should include information about birth control. Almost two-thirds say that courses should include information about abortion, sexual intercourse, and premarital sex (Debra and DeMauro, 1990). Parents of students show their support for sexuality education in other ways. When given the option of excusing their children from sexuality education classes, less than 5 percent do so (Haffner, 1994).
Mirroring public opinion, 47 states either recommend or mandate sexuality education; every state recommends or mandates AIDS education; and 38 states plus the District of Columbia and Puerto Rico have developed either state curricula or guidelines to shape the implementation of programs at the local level. Almost all state curriculum guides include abstinence messages as well as positive and affirming statements about human sexuality; topics most commonly covered are body image, reproductive anatomy, puberty, decision-making skills, families, abstinence, STDs, HIV and AIDS, sexual abuse, and gender roles (Haffner, 1994).
Despite the public support and state policies, available school-based information and education about human sexuality in general and contraception in particular are insufficient in a number of ways. First, while it is true that many states require schools to provide sexuality education and HIV/AIDS education to students at different grade levels, it is also the case that in many states, the content of those educational programs is limited by statute or by state policy or both (The Alan Guttmacher Institute, 1989). The precise nature of these restrictions can serve to limit the effectiveness of the educational programs by, for example, prohibiting explicit discussion of topics directly related to pregnancy prevention, such as contraception.
Second, a recent survey of state sexuality education curricula and guidelines revealed important gaps. The survey found that although contraception is included in a majority of the state guides, the coverage is often incomplete. Only
10 states have unambiguous messages about contraception at the junior high school level, and Iowa alone clearly includes introductory material at the elementary grade level. Only three states include coverage of contraception at both the junior and senior high levels, and condoms are mentioned in just five state curriculum guides. States vary as to which details they discuss concerning contraception, from simply identifying the concept to explaining the range of contraceptive techniques and relative effectiveness. Discussing contraceptive use with a partner is rarely covered. A 1992 study of HIV and AIDS education programs nationwide found a similar lack of prevention information; only five states adequately discussed condom use (Haffner, 1994). Moreover, it is apparent that many of the available instructional materials, particularly those provided by state agencies, are inadequate, as is the training provided to teachers of sexuality education (The Alan Guttmacher Institute, 1989). For example, a 1987 survey of secondary school sex education teachers found clear evidence of misinformation about various methods of contraception; 77 percent held the erroneous belief that women taking oral contraceptives should stop from time to time to "give the body a rest" (Forrest and Silverman, 1989).
A different, slightly dated analysis, the National Longitudinal Survey of Youth (NLSY)—a survey of a nationally representative sample of more than 12,000 young people aged 14–22 in 1979, who were reinterviewed in 1984 at ages 19–27—paints an equally checkered picture. Marsiglio and Mott (1986) found that by age 19, a bare majority (60 percent of the men and 52 percent of the women) reported that they had taken a sex education course in school, although the probability of having taken a sex education course in early adolescence was seen to increase over time. Even those who had taken a course, however, revealed important gaps in knowledge about such basic issues as when in a woman's menstrual cycle she is relatively more and less fertile.
One of the most important and sobering findings of the NLSY is that many teenagers become sexually active before having taken a sex education class. The investigators concluded: "Among young people who waited until age 18 to start having sex, 61 percent of women and 52 percent of men had already been exposed to a sex education course …; but among those who started at 16 or younger, fewer than half—in the case of males, considerably fewer—had taken a course. Furthermore, only 35 percent of young people who became sexually active at age 18 had previously received course instruction about where to obtain contraceptives, and only about 57 percent of the more limited group of course takers had received such instruction" (Marsiglio and Mott, 1986:160).
The issue of the effects of such instruction on the sexual and reproductive behavior of young people has been passionately debated, with opponents claiming that it actually increases the level of sexual activity which in turn leads to nonmarital pregnancy and other problems, and proponents denying any such effect and claiming that it probably reduces the rate of pregnancy by promoting
more effective contraceptive practice. It is difficult for research to resolve this debate definitively because of the wide variation in the content and depth of the sex education offered, differences in the research definitions of "sex education," the reluctance of schools and agencies to allow evaluation of the effects of such courses, and deficiencies in some study designs (Furstenberg et al., 1985; Kirby, 1984; Scales, 1981; Spanier, 1976).
There are, however, several bodies of information that shed light on this topic. National survey data present mixed results, but indicate that adolescents who receive sex education are more likely to use contraception than those who do not receive such instruction (Ku et al., 1993, 1992; Dawson, 1986; Marsiglio and Mott, 1986; Furstenberg et al., 1985; Zelnik and Kim, 1982). Retrospective surveys, however, cannot provide causal associations; such associations can only be made through evaluations with experimental or quasi-experimental designs. Unfortunately, few evaluations are so methodologically rigorous, and most fail to measure behavior change and long-term program effects (Chapter 8).
In an attempt to address the lack of rigorous assessment, Kirby (1984) used quasi-experimental designs to evaluate 15 well-regarded sex education curricula from the 1970s and early 1980s. He concluded that the programs did increase knowledge about various topics in reproductive health, but did not change sexual behavior or contraceptive use.
This discouraging picture appears to be changing. In a 1994 review, Kirby and colleagues suggest that both programs and evaluation methods have improved. Evidence from more than 20 surveys and studies of school-based sex and HIV and AIDS education programs indicates that specific programs delayed the initiation of intercourse, reduced the frequency of intercourse, reduced the number of sexual partners, or increased the use of contraceptives. In addition, available data indicate clearly that participation in these sexuality education programs has not been found to encourage adolescents to initiate sexual intercourse, or to increase the frequency of intercourse among adolescents who were sexually active before the program.
The sex education programs reviewed by Kirby and colleagues (1994) clustered into three types: (1) abstinence-only programs that do not discuss contraception, (2) sexuality or AIDS education programs that discuss both abstinence and contraception, and (3) programs that provide comprehensive reproductive health education covering many topics including contraception and abstinence, as well as clinical services. Abstinence-only programs appear to affect attitudes regarding premarital intercourse, but the few evaluations that measure behavior change are limited by methodological problems, and there is insufficient evidence to determine whether abstinence programs delay the age of first intercourse or affect other sexual and contraceptive behaviors. Effects of programs of the second type are mixed, but those that most successfully delay sexual intercourse or increase contraceptive use appear to focus on the "particular facts, values, norms, and skills necessary to avoid sex or unprotected
sex" (Kirby et al., 1994:355). The impact of school-based or school-linked reproductive health services is inconclusive, but the largest behavioral effects are observed in sites with strong educational components. Although these programs may not represent the average school-based sex education curriculum in current use (see, for example, Firestone, 1994), many communities are attempting to replicate the more effective models in new sites. In Chapter 8, several of these carefully evaluated programs are discussed in more detail.
A final point needs to be made. Whatever the merits of the various school-based programs being developed around the country, there are virtually no parallel programs for older men and women. Perhaps there is an unstated national belief that adults already know enough about reproduction, contraception, and related topics, or that what they do not know they can find out. Perhaps the absence of an institutional base, like the school system, for offering education about reproductive health to adults explains the gap. Whatever the reason, inadequate contraceptive use is seen in all age groups, not just adolescents, and therefore adults too may benefit from better information and education in this area.
Access to Contraception
To what extent is inconsistent or nonuse of contraception, and therefore unintended pregnancy, due to a lack of access to birth control services and supplies? In particular, to what extent is there limited access to the more effective methods of birth control, leading couples to rely on less effective methods which, by definition, have higher failure rates?
Unfortunately, answering these questions is difficult because access varies by the method being considered (condoms versus hormonal implants, for example), and because contraception can be secured through a variety of sources and systems—from pharmacies and condom boutiques to clinics, hospital centers, and private physician offices. Nonetheless, this topic attracts strong opinions on both sides. On the one hand, some have argued that, with condoms and spermicides available in virtually every drugstore, allegations of limited access to contraception are clearly fatuous. On the other hand, public health analysts point with alarm to the decline in constant dollar support for the Title X program (the family planning grant program authorized under the Public Health Service Act that targets reproductive health services to low-income women and adolescents) (Ku, 1993; Gold and Daley, 1991), and to the major financial barriers to care that women may experience, both those with private health insurance and those without, when they try to obtain the more effective methods of contraception (Kaeser and Richards, 1994).
There is widespread agreement, however, that whatever access problems exist, they pertain more to methods requiring a medical visit, such as oral
contraceptives, than to nonprescription methods such as condoms or spermicides, which can be secured from many different types of facilities. Condoms in particular are increasingly available through a particularly wide variety of sources, including vending machines, largely in response to concern over the spread of various STDs including AIDS. Unfortunately, these nonprescription methods have significant failure rates and therefore appreciable rates of unintended pregnancy are associated with them. Nonetheless, they do provide more protection against unintended pregnancy than no method at all, and as such are an important part of pregnancy prevention. In this context, it is important to note that the number of nonprescription contraceptive devices—never very large—has recently been depleted by the removal of the contraceptive sponge from the market, leaving condoms and spermicides as the only nonprescription methods now available.
The importance of inquiring carefully into contraceptive access is suggested by international comparisons of contraceptive use and various markers of unintended pregnancy and abortion. For example, a cross-national study completed by The Alan Guttmacher Institute considered the factors that might help to explain the higher rates of adolescent pregnancy, abortion, and childbearing in the United States as compared with those in various other industrialized countries (Chapter 2). One of the main conclusions of that analysis was that in those countries reporting more favorable rates, contraceptive services were apparently widely available, confidential, and very inexpensive, if not free (Jones et al., 1986). An additional analysis that examined adults as well as adolescents elaborated on this observation. The investigators concluded that contraceptive use—and, in particular, use of the more effective methods—was favorably affected by such factors as the presence of a national health plan or health care system that includes family planning services and that covers all citizens; the full integration of family planning services into general health care services, rather than such services being separate or specialist-based; the fact that family planning clinics are seen as serving all women, not just those who are poor or adolescent; the availability of free or subsidized supplies (oral contraceptives in particular); and supportive attitudes among providers (especially relevant to the prevalence of sterilization) (Jones et al., 1989). The importance of ease of access to contraceptive care also emerged from a comparison of U.S. and Danish family planning policies and practices. David and colleagues (1990) report that all people born or living in Denmark are entitled to free contraceptive counseling from a variety of sources, including the network of general practitioners who encourage the use of the more effective methods of contraception and make them readily available.
Other cross-national comparisons are consistent with these perspectives (Klaus, 1993). Miller (1993, 1988), for example, suggests that the more favorable rates reported by numerous Western European and other industrialized countries on such maternal and child health measures as infant mortality reflect,
in part, the more generous policies and benefits that these countries offer pregnant women and young families. It may be that these supportive policies also make women less inclined to recall pregnancies as unwanted or mistimed. They may also help to encourage better contraceptive use, as evidenced by their lower rates of unintended pregnancy (Chapter 2), both by enhancing access to family planning services and by strengthening the consensus that pregnancy and childbearing are too important to be undertaken casually, accidentally, or unintentionally.
Data on Overall Access
A variety of data sets are available to consider recent trends in access to contraceptive services. In the aggregate they give a mixed picture. Using the National Survey of Family Growth (NSFG), Mosher (1990) concluded that the proportion of all women aged 15–44 who have had one or more "family planning visits" in the preceding year did not change significantly between 1982 (37 percent) and 1988 (35 percent), and that this evidence of little or no change held across all age and income groups.
However, investigators at the Center for Health Economics Research, using the same data set, recalculated the proportions who had had a family planning visit on the basis of the number of women in each category who were estimated to be sexually active (or were planning to be), and concluded that, among this subset, there was an important decline in family planning visits among teenagers and among both poor (below 200 percent of the poverty level) and nonpoor women between 1982 and 1988. For example, they calculated that of sexually active women under age 20 in 1982, 65 percent had had a family planning visit in the preceding year, versus 57 percent in 1988; for poor women, the figure was 46 percent in 1982 and 42 percent in 1988 (Robert Wood Johnson Foundation and the Center for Health Economics Research, 1993). The investigators believe that these data reflect increased problems with access to contraceptive services (although they may also reflect decreased interest in securing contraception).
Bits of information from various parts of the country suggest that access to the more effective methods of contraception—that is, those requiring some sort of contact with the health care system—may be constrained, particularly in the public sector. For example, in December 1992 and January 1993, a team from the New York City Mayor's Advisory Council on Child Health called 115 service sites that offer family planning care in the city to request an appointment for contraceptive services; one-third of the callers were not able to make an appointment at all, and the rest confronted significant difficulties and delays. The authors concluded that because the family planning system was so underfunded and poorly organized, access was very limited and that, in addition, succeeding
in the task of making a family planning appointment in the New York City system requires ''motivation, persistence, and fortitude" (Mayor's Advisory Council on Child Health, 1993). Additional material on this study appears later in this chapter.
A somewhat similar 1994 report of Colorado family planning clinics noted an average wait of three weeks for a contraceptive appointment; reducing this wait by, for example, opening weekend or evening clinics, was not possible given available resources (J. Henneberry to J. DeSarno, pers. com., 1994). And in the District of Columbia, some family planning clinics report waiting times of over 25 working days between the first call and an appointment (R.S. Guy, pers. com., 1994).
Adolescents may face particular barriers in obtaining the more effective methods of contraception owing to variations among providers regarding the circumstances under which they will provide family planning services to adolescents, especially if there is no parental involvement. Some providers, for example, decline to offer contraceptive care to adolescents because of insufficient knowledge about legal requirements in this area; others may object to offering contraceptive care to minors without parental consent. Although the Title X program was designed in part to increase access to contraception among adolescents, the limited financing and reach of that program means that access barriers continue to exist for this age group in some communities.
Nonetheless, it is important to mention again that most women not actively seeking pregnancy use contraception, and as a general matter, contraceptive use has increased in recent years, including among men (Chapter 4). Among those few women who are not seeking pregnancy but are not using any method of contraception, the vast majority have used a method at some point. Based on a 1993 follow-up telephone interview of women aged 20–41 from the 1993 National Survey of Women (NSW), Sonenstein and colleagues (1994) recently reported that 80 percent had had a "reproductive health visit" (defined to include contraceptive care, if desired) in the past year—a figure that rose to 90 percent for a visit in the past two years. Data such as these suggest that, in one way or another, most women and men have found ways to secure and use one or more methods of birth control.
The problem with this more favorable picture is that even if most people use contraception most of the time, and even if access to the best methods of contraception is more or less adequate in most places, the net result will be an appreciable level of unintended pregnancy, given the relative ease with which pregnancy occurs. Preventing pregnancy requires scrupulous use of the best methods—not some of the time but all of the time. Therefore, even modest problems in access to contraception, as available data certainly suggest, are enough to facilitate unintended pregnancy.
In the next several subsections, some specific factors that may limit access to contraception are explored: various financial issues including contraceptive
pricing and public investment in family planning services, problems in the provider base for contraception, and general bureaucratic complexities. The next main section explores the proposition that many opportunities to provide contraceptive information and services are being missed.
As is the case for a wide variety of health care interventions (see, for example, Stoddard et al., 1994), insurance coverage affects access to contraception (Kirkman-Liff and Korenfeld, 1994). For example, in the 1993 NSW survey of more than 1,000 women aged 21–40 mentioned earlier, Sonenstein and colleagues (1994) found that whether or not a reproductive health visit had occurred was heavily influenced by the presence of health insurance and a regular source of care. Overall, 20 percent of the sample had not had a reproductive health visit in the past year; however, for those without a regular source of care, the figure was 39 percent; for those without health insurance altogether, the figure was 42 percent.
With regard to private insurance, the 1988 NSFG revealed that, overall, private insurance does not lie behind most family planning visits. In that year, about 41 percent of all women who received family planning services reported paying for their most recent visit out of their own pockets. Another 17 percent said they used insurance with a copayment or deductible. Insurance completely covered only 25 percent of recent visits, and 7 percent of visits were covered by Medicaid. The remaining services were provided at no charge to the client (Kaeser and Richards, 1994).
This modest presence of private insurance as a financing source for contraceptive services is consistent with the historic traditions of private-sector health insurance coverage—providing coverage of surgical services but not covering preventive care. A 1994 study by The Alan Guttmacher Institute of the coverage of reproductive health services in various insurance and financing plans concluded that although 85 percent or more of typical private health insurance policies cover sterilization services and 66 percent cover abortion, coverage of reversible contraception was appreciably thinner. None of the five reversible methods included in the study—intrauterine devices (IUDs), diaphragms, hormonal implants and injectables (e.g., Norplant and Depo-Provera), and oral contraceptives—is routinely covered by more than 40 percent of typical plans. Furthermore, half of the large-group plans cover no methods at all, and only 15 percent cover all five. Notably, even though oral contraceptives, the most
commonly used reversible methods, are routinely covered by only one-third of large-group plans, this did not result from a failure to cover prescription drugs. Although virtually all of the plans typically cover prescription drugs, two-thirds of these do not routinely cover oral contraceptives. Similarly, although more than 90 percent of the plans typically cover medical devices in general, less than 20 percent of these plans cover IUDs or diaphragms and 25 percent cover hormonal implants. In addition, the study found that less than a fourth of the plans routinely cover contraceptive counseling (The Alan Guttmacher Institute, 1994). Thus, many privately insured women who need contraceptive care must go out of plan and pay for it themselves, use over-the-counter methods that may be less effective, or not use any method at all.
Health Maintenance Organizations
Demonstrating their emphasis on preventive care, many health maintenance organizations (HMOs)—although not all—provide more comprehensive coverage for contraception than do typical fee-for-service plans. Only 7 percent of HMOs provide no coverage at all, and 40 percent cover all five methods noted above. Still, coverage of the various methods is far from uniform or complete, from 59 percent for Norplant insertion, to 84 percent for oral contraceptives, to 86 percent for IUD insertion. However, coverage of contraceptive counseling is routinely covered by at least 90 percent of HMOs. Even though HMOs cover a wider range of contraceptive services than do private plans, they nonetheless frequently require copayments for those services, which may serve as a deterrent for some women (The Alan Guttmacher Institute, 1994). In addition, adolescents especially may be reluctant to obtain contraceptive care as a dependent in a managed care setting, fearing that confidentiality will not always be maintained.
It is important to stress that these data on HMOs do not necessarily reflect the practices of all managed care arrangements, including both Medicaid managed care systems and for-profit networks. There are an increasing number and variety of such arrangements, but no data are available to assess how they address contraceptive services and supplies. Particularly in systems that are highly cost-competitive, coverage of both preventive services and prescription drugs (within which many of the more effective reversible methods of contraception fall) may be limited.
Public Sector Programs
In contrast to private insurance coverage and HMOs, the Medicaid programs of all 50 states and the District of Columbia provide reimbursement for contraceptive services, as required by law. Moreover, since the late 1980s,
Medicaid has become the principal source of public funding for contraceptive services, accounting for 58 percent of all federal family planning expenditures (and 43 percent of all public family planning expenditures), or approximately $270 million in 1990. Between 1984 and 1991, Medicaid spending for family planning services increased 41 percent and the number of clients served increased 31 percent (Ku, 1993). Nevertheless, as noted earlier, only 7 percent of all family planning visits are covered by Medicaid (Kaeser and Richards, 1994).
Women who use Medicaid to obtain family planning services do so in a wide variety of settings, from private physician offices to public clinics. Unfortunately, no systematic data are available to determine whether Medicaidenrolled women who try to obtain prescription-based methods of contraception have appreciable difficulty in finding a provider who will accept them and their payment source. However, this problem has clearly affected access to prenatal care and to many other services as well. Although federal law requires states to set reimbursement rates in the Medicaid program that are adequate to ensure the participation of sufficient numbers of providers, particularly those providing pediatric services and services to pregnant women, this requirement has not been enforced effectively (Institute of Medicine, 1988). The increasing tendency to place the Medicaid population in managed care networks has undoubtedly affected their overall ability to obtain health services, but the direction of the change, and how access to contraception in particular has been affected, is not yet well understood (National Academy of Social Insurance, 1994).
Not all low-income women quality for Medicaid. In most states, Medicaid coverage is tied to eligibility for Aid to Families with Dependent Children (AFDC), which usually means that a woman must be single and have at least one child. Furthermore, Medicaid eligibility levels in many states are extremely low—nationwide, the average income eligibility level is an income that is 50 percent of the poverty level, or $5,945 a year for a family of three. In recent years, Congress has passed a series of measures that were intended to help break the link between AFDC and Medicaid by allowing pregnant, low-income women and their young children with incomes up to 133 percent of the poverty level (and, at the state's option, up to 185 percent) to qualify for Medicaid, even if they were not receiving AFDC. The recent increases in Medicaid as a financing source for contraceptive services may reflect, in part, these eligibility expansions. Pregnant women who would not otherwise qualify for Medicaid (i.e., non-AFDC recipients) remain eligible for 60 days postpartum; thus, during that period, women are covered by Medicaid for family planning services. After 60 days, however, their coverage ends, unless states cover these services themselves, meaning that Medicaid cannot be relied on as a steady source of contraceptive financing for the most effective methods, except for the poorest women (Kaeser and Richards, 1994).
Adolescents may find it especially difficult to rely on Medicaid as a financing source for contraception. Even after the eligibility expansions of the 1980s, noted just above, states are only required to cover individuals (who are not pregnant, postpartum, under age six, or linked through a categorical program such as AFDC or Supplemental Security Income [SSI]) up to 100 percent of the federal poverty level if they are born after September 30, 1983. This means that all adolescents up to age 19 do not have to be covered until the year 2002. Even in those states that have chosen to provide Medicaid coverage to the poor and low-income adolescent population at an earlier date, adolescents may experience particular difficulty establishing Medicaid eligibility or utilizing Medicaid coverage independently of their parents and thus may be unable or unwilling to rely on Medicaid as a source of funding for the family planning services they need. The limited enrollment of adolescents in the Early and Periodic Screening, Diagnosis and Treatment program within Medicaid also suggests that the full potential of this part of the Medicaid program for providing teenagers with contraceptive services, including on-going assessment and counseling, has not yet been realized.
Many women with Medicaid coverage, as well as women with neither private health insurance nor Medicaid coverage, secure family planning care through a network of almost 5,500 clinics that obtain an appreciable portion of their funds from public sources, including the Title X program, and the Maternal and Child Health Services Block Grant, as well as the Title XX Social Services Block Grant, and federal, state, and local funds. Of these clinics, more than 4,000 receive some Title X funds (Henshaw and Torres, 1994). Anyone may seek services at a Title X-funded clinic; lower-income women may receive free services depending on their ability to pay. By law, women, including adolescents, whose incomes fall below 100 percent of the poverty level must receive fully subsidized services; women whose incomes are between 100 and 250 percent of the poverty level may receive services on a sliding-scale basis. Women whose incomes are above that level must pay the clinic's full fee, which is usually less than would be charged by a private practitioner.
A recent study of this network of clinics assessed trends in their sources and amounts of public support. Major conclusions included the following: for these clinics, Title X funding fell by roughly half between 1981 and 1991, after adjusting for inflation, and their overall level of federal revenue (including Medicaid and several other federal sources as well) fell 38 percent over this same interval; Title XX (Social Services Block Grant) funding for these clinics took a particularly sharp decline. This loss of federal funds was cushioned by growth in various other revenue sources; for example, funding from state and local sources grew by 112 percent and private revenue climbed 82 percent (again, in constant dollars). The net effect of these many changes was that the total revenue available to this clinic system from all sources, both public and private, fell 6 percent, from $518 million in 1981 to $485 million in 1991 (using
1991 constant dollars) (Ku, 1993). These findings are generally consistent with an earlier analysis, using a somewhat different set of data and definitions, which found that public expenditures for family planning declined by a third between 1980 and 1990 (Gold and Daley, 1991). Unfortunately, data are not available on trends in the total dollar amount spent in the United States for family planning services in general.
Curiously, this net decline in public investment was not reflected in declining numbers of clients receiving care in this clinic system. Ku (1993) reports that the number of women receiving care rose 17 percent between 1981 and 1991, from 3.8 million to 4.5 million. Although there is much speculation about the meaning of serving more clients through family planning clinics with less money (was the quality of care compromised? did clinics become more efficient? were important ancillary services reduced?), the precise impact is still under investigation.
The decline in public support, variously measured, is troubling given the evidence that, as Donovan (1991) has noted, clinics are "facing higher costs and sicker patients." For example, the Family Planning Council of Southeastern Pennsylvania reported in 1991 that it now spends more on medicines to treat STDs than on contraceptive methods—just the opposite of the case 5 to 8 years ago; and in the state of New York, visits to family planning clinics for treatment of STDs since 1984 have risen almost 80 percent. These reports are mirrored around the nation as the number and spread of STDs escalate.
Moreover, the costs incurred by family planning clinics have risen sharply in recent years. In 1992, new rules were issued to implement the Clinical Laboratories Improvement Act, a sweeping reform of the nation's clinical laboratory system. Depending on the complexity of the tests performed at a clinic, compliance with the new regulations on hiring of new personnel, retraining, new administrative costs, and annual registration and inspection fees that in many cases had not been budgeted, costs rose by up to $3,000 per site. Pap smears in particular reflect these rising costs. For example, 25 agencies in Colorado funded by the state health department to do family planning paid $200,000 to $300,000 more in 1991 for Pap tests than they did in 1990. Another set of regulations implementing the new Occupational Safety and Health Act standards on blood-borne diseases may also have added new costs to family planning clinics. One Title X grantee, Planned Parenthood of Wisconsin, estimated the total costs of complying with the regulations for its clinic network at $64,425, or approximately $1,611 per clinic for each of its 40 clinics (Kaeser and Richards, 1994).
One particular aspect of financial barriers that merits mention is the possibility that the cost to consumers of various methods of contraception may affect method choice and, in particular, limit access. Common sense suggests that pricing affects choice of method, but few data are available from the United States to understand the dimensions of this influence on contraceptive use generally or on the choice of method in particular (see Appendix G for a discussion of selected cost issues).
Policymakers and family planning program administrators believe that consumer cost affects access and use, as demonstrated by the policy of "public sector pricing" of contraceptive devices. Some U.S. pharmaceutical companies offer oral contraceptives (OCs) at a significantly reduced price to various nonprofit and public family planning programs (e.g., Planned Parenthood, Title X programs, and other public sector clinics), thereby allowing them to provide OCs to clinic clients at well below market price or provide them for free. Program leaders believe that offering such prescription methods at low or no cost increases their use, particularly given the heavy representation in these clinics of low-income women and adolescents.2
Recently, the pricing of contraceptives has been questioned in relationship to both the cost of manufacturing some methods and the relative public-private investment in their development. With regard to the first issue, for example, the production cost for each monthly cycle of OCs is typically in the range of $0.15, based on the cost of bulk purchasing by the U.S. Agency for International
Development, yet the current market price to consumers in New York and elsewhere is around $20 per cycle (A. Rosenfield, pers. com., 1994).
With regard to the second issue, a number of critics have argued that the pricing of Norplant (about $365) may not adequately reflect the substantial investment of the U.S. government in developing the method, and that the original price per Norplant kit was in excess of costs and seemed to be based only on what a consumer would pay for five years of OCs (which are roughly similar in effectiveness to Norplant) (A. Rosenfield, pers. com., 1994). Although a public sector pricing structure for Norplant is now being developed, its details are not yet clear, and field experience continues to suggest that the high cost of the device remains a barrier to its use (Frost, 1994), particularly because the base charge of $365 is often supplemented by additional insertion fees and other charges, which may bring the total to well over $500 or more. Although all 50 states and the District of Columbia offer Medicaid financing for Norplant insertion, many low-income women are not eligible for Medicaid and have no private health insurance coverage. For them, Norplant is accessible only if sliding fee scales are available, typically in publicly subsidized clinics, or the out-of-pocket costs are manageable (Kaeser, 1994). Moreover, as noted above, private insurance coverage as well as the coverage offered by HMOs and other systems can be spotty.
The issue of Norplant removal has recently become more visible as exemplified by a recent class action liability lawsuit based on alleged removal problems. For a variety of reasons, including recent television programming that has stressed the undesirable side effects of Norplant, many facilities are reporting an increase in requests for removal. Some state Medicaid programs will not pay for the removal of a device inserted while a woman was on Medicaid if, at the time she requests removal, she is no longer enrolled in Medicaid; other restrictions may apply as well. In response, some clinics serving predominantly low-income women (such as the Los Angeles Regional Family Planning Council) have created special funds to help finance the removal of the implants.
The Provider Base for Contraception
This section considers the possibility that access to contraception may be constrained by the limited training offered to physicians and other health professionals regarding contraception. The importance of provider training is confirmed by data on access to Norplant. Frost (1994) reported that of those organized family planning providers (i.e., clinics, not private physicians) who were not able to offer the implant to their clients, 60 percent suggested that the absence of a person trained in insertion and removal was a major contributing factor.
Even though obstetrician-gynecologists, internists, and general and family practitioners are the most common physician providers of contraceptive information and services to women and men, the guidelines for these specialties include very little required training in the general area of pregnancy prevention. Moreover, there is limited attention in training programs to the special needs or preferences of various groups at especially high risk of unintended pregnancy. Adolescents, for example, often require carefully designed, age-appropriate services and counseling that may be appreciably different from the services offered to adult men and women. Although specialists in adolescent medicine receive training about just these sensitivities, most physicians do not. Accreditation requirements for postgraduate training, established by the Accreditation Council for Graduate Medical Education (ACGME), are often vague regarding knowledge necessary to offer comprehensive contraceptive services, including adequate counseling and education for various groups who may have special needs. For example, the current requirements for residency training in obstetrics and gynecology state only that education must include "clinical skills in family planning," leaving the content of the curriculum open to variation (American Medical Association, 1994). ACGME has recently revised these requirements to be more comprehensive, stating that programs "must provide a structured didactic and clinical training experience in all methods of family planning" (Accreditation Council for Graduate Medical Education, 1995). These new provisions will become effective in January 1996.
Because the ACGME requirements are presently so nonspecific, residency programs have inconsistent standards for their contraceptive training. The repercussions of these varied standards are evident in a 1993 survey of obstetrics and gynecology residency program directors and chief residents across the country. In that survey, less than two-thirds (63 percent) of program directors indicated the presence of a faculty member associated with their program having a special interest in family planning, and only 13 percent of surveyed programs included an official family planning rotation. Although some programs allowed students to seek training in contraception and abortion in affiliated or nearby clinics, time constraints and other reasons prevented many students from doing so. Consequently, 38 percent of the students queried had never inserted an intrauterine device, 11 percent had never fitted a diaphragm, and an additional 43 percent had fitted a diaphragm less than 10 times. Clinical experience with oral contraceptives and sterilization is apparently rich, but obstetrician-gynecologists trained solely in these methods are unlikely to prescribe other methods that their patients may find preferable for any number of reasons (Westoff et al., 1993). And training—even basic information—about the uses of emergency contraception is exceedingly thin (F.H. Stewart, pers. com., 1994). A recent study of internal medicine and family practice residents indicates that they may also be inadequately trained to care for women of reproductive age.
Of those surveyed, over 40 percent failed to indicate that they would provide female patients with information about family planning options, STDs, and safer sex (Conway et al., 1995). The closely related issue of training in abortion is discussed in Chapter 7.
Despite low minimum competency requirements in the area of family planning, some graduate programs recognize the need for providers to be well trained in contraception and therefore offer thorough preparation as part of their curricula. For example, the University of California at San Francisco, the University of Pittsburgh, and the University of Maryland have each established fellowship programs that provide intensive training in family planning to obstertrician–gynecologists who have completed their residencies (M. Creinin, pers. com., 1994).
The fact that some programs provide adequate training, of course, does not guarantee that a graduated resident will go on to provide contraception. Some general and family practitioners choose to offer no contraceptive services, and about one in five general and family practitioners does not provide reversible contraceptive services because of such factors as the relatively low pay for such services, religious or moral objections, or simply a discomfort with sexuality and related issues (Orr and Forrest, 1985). A recent Centers for Disease Control and Prevention (1994) survey on HIV prevention practices revealed that 25 percent of all physicians felt their patients would be offended by questions regarding their sexual behavior. Physicians who are reluctant to discuss sexual behavior in the context of something as perilous as the HIV epidemic may be even less likely to raise the issue in regard to pregnancy prevention. Additional data confirm this general finding. A recent Harris survey commissioned by the Commonwealth Foundation found that although the vast majority of Americans had seen a health care provider in the last year, only a small portion reported that either contraception or prevention of STDs was mentioned by the provider (Commonwealth Foundation, 1994).
It is important to pinpoint an additional reason that some providers may approach contraception gingerly—fear of liability exposure and litigation. Liability concerns within both the pharmaceutical and provider communities not only decreased the variety of intrauterine devices available in the U.S. market in the 1980s but currently also limit the number of physicians, including obstetrician–gynecologists, willing to insert the few now on the market (Forrest, 1986). Emergency contraception shares some of the same burden. Oral contraceptive manufacturers have not applied for U.S. Food and Drug Administration approval to market oral contraceptives for use as emergency contraceptives, citing, among other reasons, that they are concerned about the liability issues that such use might raise (F.H. Stewart, pers. com., 1994). Whatever the merits of this concern, the main barrier to wider use appears to be the lack of knowledge about the method among both providers and the women they care for, as noted above (Trussell et al., 1992).
Although there seems to be an emerging consensus that the nation needs more primary care and general practitioners, specialization remains a more profitable and intellectually challenging option for many medical students, and it may well be many years before the supply of primary care and general practitioners catches up with the need. Nurse practitioners and advanced-practice nurses are being relied on in increasing numbers to provide primary care to patients, and many studies have indicated that the basic health care provided by nurses is of high quality (Mundinger, 1994). Nurses' effectiveness in promoting health, communicating with patients, adapting medical regimens according to patient preferences and environments, and using community resources make them prime candidates for encouraging contraceptive use as well. A recent survey confirmed their commitment to contraceptive access: a self-administered questionnaire surveying graduates of five reproductive health nurse practitioner programs in the United States revealed that 56 percent of the respondents were currently employed by a Title X agency (National Association of Nurse Practitioners in Reproductive Health, 1994). Even though many nurses are presently providing selected contraceptive services, the role that nurses play in providing access could undoubtedly be increased.
In day-to-day life, the specific barriers to access outlined thus far, such as limited insurance coverage and insufficient provider training, can interact with each other and with additional obstacles to produce a bureaucratic tangle that undoubtedly limits access to contraception. After all, the medical services required to secure the more effective forms of contraception in the United States are embedded in the nation's general health care system, with its well-described problems of geographic maldistribution of providers, problems in locating transportation to service sites, bureaucratic delays in arranging for care, difficulty even in finding the telephone number to call for services, seeing different providers at each visit, absence of translators, long waits for appointments and in the waiting rooms once an appointment is in hand, and so forth. These general barriers are not detailed here because they have been well covered in previous reports from the Institute of Medicine (1994, 1988) and from many other sources.
Several case studies specific to contraceptive access illustrate the point, particularly the New York City study noted earlier. As described above, in December 1992 and January 1993, a team from the New York City Mayor's Advisory Council on Child Health called 115 service sites that ostensibly offer family planning care in the city to request an appointment for contraceptive services. In over one-third of the cases, even the English-speaking callers were not able to make an appointment at all, although this figure varied by type of
clinic. The two most common reasons for the inability to make an appointment were no one answering the phone at all (five or more attempts were made) and being told that a doctor's referral was necessary before an appointment could be booked. Other reasons included requirements that a woman register at a clinic in person before an appointment for family planning could be made, and the absence of a doctor to offer care. Even those who were successful in making appointments frequently were put on hold repeatedly, sometimes for over 30 minutes. For those able to make an appointment, the mean number of days between the call and the appointment for all types of facilities was 20 working days, with the range in means across facilities being 10-51 working days. When the callers mentioned that they ''had no insurance," 4 in 10 were asked to bring cash to cover the full anticipated charges, which averaged $79.00. The authors concluded that because the family planning system was so underfunded and poorly organized, access was very limited and that therefore, as noted earlier, succeeding in the task of making a family planning appointment in the New York City system requires "motivation, persistence, and fortitude" (Mayor's Advisory Council on Child Health, 1993).
Female sterilization offers another example of multiple entanglements. Despite the heavy reliance by American women on sterilization (Chapter 4), data suggest that bureaucratic and institutional barriers may limit access to this procedure. For example, federal regulations for subsidized sterilization mandate a strict set of policies with which a provider must comply, including sterilization counseling, a signed consent form, a required 30-day delay between signing the consent form and performing the sterilization, and performing the procedure not less than 30 but no more than 180 days of the consent being signed. The intent of these policies is to protect women by ensuring informed and timely consent, and with good reason, given the past history of abuses (Chapter 7). But it is also true that the protective policies can sometimes create administrative burdens for hospitals and clinics that may limit the number of facilities offering this procedure—an outcome that may have the effect of placing additional burdens on low-income and minority women, the very women the policies were intended to protect. Physicians themselves may place additional requirements on women, thus hindering access to sterilization. Klerman and colleagues (1993) note that to minimize legal liability, operative risks, or risk of patient regret, physicians may require patients to lose weight prior to surgery, stop smoking, obtain a more extensive laboratory workup, be happily married, have a certain number of children, or be a certain age. Many low-income men also may find it difficult to obtain a sterilization. For example, less then 20 percent of publicly supported family planning clinics report providing male sterilization services (Burt et al., 1994).
Hospitals that accept federal reimbursement for sterilization procedures often have long waiting lists for female sterilization because of the unavailability of physicians or operating rooms, the loss of patient records and consent forms,
delayed laboratory tests, payment issues related to Medicaid eligibility, and the requirement in some states that the federal consent form be placed in the record preoperatively (Klerman et al., 1993). These problems can delay the procedure beyond the 60-day postpartum period so that a woman is no longer eligible for postpartum Medicaid coverage, or in some extreme cases, the procedure may be delayed past 180 days, resulting in a woman needing to start the administrative and consent procedure all over again. The 30-day waiting period can also be particularly burdensome. For example, if a woman signs a consent form while she is pregnant, asking to be sterilized at the time of delivery, a full 30 days must pass before the request can be honored. If by chance she delivers before the 30 days are up, the sterilization cannot be performed at the time of delivery, thereby requiring that she return to the hospital at some later time to be sterilized. Not surprisingly, one of the effects of all of these complexities is an increased risk of unintended pregnancy among women whose requests for sterilization cannot be accommodated immediately postpartum (Davidson et al., 1990).
Thus far, this chapter has considered two broad explanations for inadequate contraceptive use: limited knowledge about and insufficient access to contraceptive services and supplies. This section considers another factor that may give some clues about how to increase both contraceptive knowledge and access. The tendency in the United States to offer health and human services in categorical, problem-specific ways may result in missing many opportunities to offer information, education, and services that help couples avoid unintended pregnancies. In a recent editorial advocating increased attention to immunizing children, U.S. Department of Health and Human Services Secretary Donna Shalala stated, "Every encounter of any sort that a physician or provider has with a patient—whether in an office or an emergency department or a hospital room—offers an opportunity to screen children for needed vaccines and administer appropriate vaccines immediately." Such screening "should become as routine as measuring blood pressure in adults" (The Blue Sheet, 1993:9). This perspective has not yet been articulated for contraceptive services, even though, just as for immunizations, many opportunities are present to improve the contraceptive vigilance of adults as well as adolescents.
One example is the disinclination of many clinics that screen for and treat STDs to provide contraceptive services. Two recent investigations reveal clearly that the clients typically seen in STD clinics are often poor users of contraception, frequently have multiple sexual partners, lack much basic information about pregnancy and reproduction, and would be receptive to more information and to additional services to address their contraceptive needs. Upchurch and
colleagues (1987) surveyed 516 women attending an STD clinic in an urban, inner-city area to learn about various contraceptive and sexual practices and knowledge. They documented high rates of STDs and STD recurrences and poor use of contraception. They concluded that making contraceptive services available in STD clinics could be of great help to the women typically seen in these clinics who are at high risk of unintended pregnancy and who are known to be poor users of contraception. Similar conclusions were reached in a more recent survey at another STD clinic (Horn et al., 1990).
The categorical, single-problem focus also means that few drug treatment programs for men or women—even for women who are new mothers—emphasize contraception or preventing unintended pregnancies (Gehshan, 1994). For example, since 1988, the federal Center for Substance Abuse and Prevention (CSAP), in conjunction with the Maternal and Child Health Bureau, has funded more than 100 programs targeted to women of childbearing age, especially those who are pregnant or have a child less than 1 year old at the time of enrollment. Although the goals of the program grants could include an emphasis on preventing unintended pregnancy, a recent review of 112 projects receiving CSAP support in 1991 revealed that none had program objectives that included pregnancy prevention, nor did any of the program evaluations focus on this issue (Cartoof, 1994). Although there are many reasons for this state of affairs—not the least being that many drug treatment personnel are not trained in this area and have few extra resources to devote to this topic—several pilot projects have demonstrated that integration of drug treatment and family planning services is not only possible but also leads to better use of contraception (Armstrong et al., 1991).
The practice patterns of pediatricians raise a similar point. Pediatricians' emphasis on preventive care makes them likely candidates to encourage the use of contraception. They are in a unique position to provide information both for their adolescent patients, many of whom have or will soon become sexually active, and for new parents as well in the form of interconceptional care. The subspecialty of adolescent medicine draws attention to the need for training in the health needs of teenagers, including those related to sexuality, but general pediatricians are only beginning to consider whether their work in protecting the health of infants and young children includes counseling mothers and couples about the need for reasonable intervals between births and the importance of being in good health before conception. The American Academy of Pediatrics reports that only 34 percent of surveyed physicians routinely ask their patients, when appropriate, about family planning (Clark, 1993). Klerman and Reynolds (1994) assert that all pediatricians should be educated to ask mothers about their plans for future pregnancies, and should be prepared to give advice about spacing of pregnancies and about contraceptive methods. They speculate that although some physicians may feel they are prying or overstepping their boundaries in discussing these matters, the issue seems very appropriate when
it is raised in the context of the physical and emotional health of the infant being examined. For example, extending the interval between pregnancies can help to increase the amount of attention devoted to the present child or children and to improve the health of future children by allowing sufficient time for maternal recovery between pregnancies. The importance of an adequate interpregnancy interval for reducing the risk of low birthweight in subsequent pregnancies has recently been well documented, lending added importance to pregnancy spacing and interconceptional care (Rawlings et al., 1995). This is not to suggest that pediatricians be equipped and prepared to carry out a full examination in preparation for providing prescription-based methods of contraception, but rather that the physician raise the subject, and when appropriate, provide counseling, encouragement, and, at a minimum, a nonprescription contraceptive method or a referral. At the same time, it is important to acknowledge that because relatively few poor or minority children see a pediatrician regularly, only part of the childbearing population would be reached by this strategy.
This notion of missed opportunities is not limited to the health sector. Many others in the helping professions are in a position to raise issues of pregnancy planning and contraception but fail to do so (Tyrer, 1994). The limited commitment of many school systems to education regarding contraception, human reproduction, and related issues has already been mentioned, and in Chapter 7, the potential role of the media in this area is also explored. Other sectors that could become involved include social service agencies, church-affiliated centers, homeless shelters, job training and employment services, and various community and neighborhood centers that provide integrated services to families. Intervention programs working with troubled families offer unique and important opportunities to engage parents in topics of pregnancy spacing and planning; for a wide variety of reasons, however, such opportunities are often passed over. Some case workers feel the subject of family planning is taboo or too controversial; sometimes the case workers sense that the underlying problems of families are so compelling that attempts to discuss family planning will be essentially futile; some perhaps fail to appreciate that improving the life prospects of the child currently in treatment will be compromised if another baby arrives too soon. Whatever the reluctance, there is a newly articulated view in the field of family-centered care, especially that provided to families with infants and toddlers, that contraception and pregnancy planning are important topics to address (Lieberman, 1993).
A somewhat philosophical explanation for these missed opportunities to offer contraceptive information and services is that in the United States and many other countries as well, there may be a tendency to "overmedicalize" family planning—that is, to make contraception (especially the more effective methods) so definitively a medical service that access is, in fact, constrained, inasmuch as access to medical care generally can be difficult (Shelton et al., 1992). This view lies behind the current interest in providing oral contraceptives as over-the-counter
rather than prescription drugs; the notion is that easing access to oral contraceptives would increase their use (Samuels et al., 1994). Similarly, some agencies are experimenting with providing the first several cycles of oral contraceptives to adolescents without requiring a pelvic examination at the outset, given that one of the reasons some adolescents are reluctant to begin using highly effective means of contraception is fear of pelvic examinations and medical procedures in general (Zabin and Clark, 1981; see also Beckman et al., 1992, and Chapter 6).
The data and perspectives presented in this chapter suggest that one of the reasons contraceptive use is inadequate—and that unintended pregnancy therefore continues to occur—is that Americans have important gaps in their knowledge about contraception in general, and about the risks and benefits of various methods of birth control in particular. The resulting fears and misconceptions can impede the use (including the continuation) of contraception, which in turn contributes to the risk of unintended pregnancy. The complexity of using some contraceptive methods properly may help to explain the observation that education and cognitive ability are positively associated with greater success in contraceptive use. Data suggest that high quality instruction in schools (only one of many information sources) about various aspects of human sexuality, including contraception, is not uniformly available nationwide; moreover, what is available may sometimes be too little and too late, inasmuch as a significant portion of young people begin sexual activity before having had the benefit of any formal education about contraception and related topics. Knowledge is increasing about how to structure school-based curricula to reduce both precocious sexual activity as well as to improve contraceptive use once sexual activity has begun. Nonetheless, all such information centers on adolescents, and little is known about how to improve the knowledge and skills of adults regarding contraception.
It is also apparent that, through a combination of financial and structural factors, the U.S. health care system makes access to contraception a complicated, sometimes expensive proposition. Condoms, the most accessible form of contraception, provide valuable protection against STDs but must be accompanied by prescription-based methods to afford maximum protection against unintended pregnancy. Unfortunately, other accessible nonprescription methods (such as foam) neither prevent the transmission of STDs nor offer the best protection against unintended pregnancy. In particular, private health insurance participates poorly in the financing of contraception; eligibility and other restrictions on Medicaid support for contraception make it a source of steady
financing only for the poorest women; and the net decline in public investment in family planning services, in the face of higher costs and sicker patients, may have led to a net decline in access to care for women who rely on publicly subsidized contraceptive services.
Finally, too few providers of health care and social services use all available opportunities to discuss contraception and the importance of intended pregnancy to the health and well-being of women and men, children, and families. Within the health care community, this may be due to limited training in contraception as well as to such other factors as personal feelings about birth control and concerns about liability. Outside of the health care community, the lack of attention may be due to a sense that contraception is a medical issue, perhaps a touchy subject, or "not part of my job." The net effect of these missed opportunities is that only a limited range of providers and institutions are involved in helping Americans to know about—and acquire the means to prevent—unintended pregnancy.
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