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The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families (1995)

Chapter: Socioeconomic and Cultural Influences on Contraceptive Use

« Previous: Personal and Interpersonal Determinants of Contraceptive Use
Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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7
Socioeconomic and Cultural Influences on Contraceptive Use

Contraceptive knowledge and access (Chapter 5) are undoubtedly shaped by the surrounding socioeconomic and cultural environment, as are personal attitudes and feelings about contraception (Chapter 6). This observation is consistent with a number of studies—often called a real research—showing that various community attributes, as distinct from individual characteristics, are associated with the likelihood of using contraception (see, for example, Mosher and McNally, 1991; Singh, 1986; Tanfer and Horn, 1985). It is also consistent with data suggesting that the more favorable rates reported by numerous Western European and other industrialized countries on such maternal and child health measures as infant mortality partly reflect the more generous policies and supports that these countries often provide pregnant women and young families (Miller, 1993). Accordingly, this chapter discusses several socioeconomic and cultural factors that, in varying ways, may affect contraceptive use and therefore unintended pregnancy: the large and increasing diversity of the U.S. population (including ethnic, cultural, and religious diversity), conflicting views of sexuality and how such views might influence the use of contraception, economic issues, the roles that racism and violence play in various aspects of reproductive life, selected aspects of gender bias that relate to unintended pregnancy, and how organized opposition to abortion might affect access to contraception.

It is not always clear what the precise relationship is between these factors and the risk of unintended pregnancy. Nonetheless, in the aggregate, they help to form the environment in which individual decisions about contraception and sexual activity occur. Consideration of them must be part of any serious inquiry

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

into the reasons that lie behind high rates of unintended pregnancy in the United States.

Diversity in U.S. Culture

The large and increasing diversity of the U.S. population is unmistakably one of its strengths, celebrated throughout the country with flair and enthusiasm. It is also a factor that makes understanding the determinants of unintended pregnancy more difficult. For example, even the concept of unintended pregnancy may be alien to some groups whose views of pregnancy and childbearing may be based more on fatalism or other value systems than the notion that these events can or should be carefully planned by such artificial means as contraception. Appreciable diversity can also complicate the task of designing culturally competent intervention programs that respect differences in feelings and values regarding unintended pregnancy, contraception, and related topics. This section briefly explores several aspects of diversity: cultural, ethnic, religious, and political.

Cultural and Ethnic Diversity

The United States is already a diverse mix of cultural, racial, and ethnic groups, and will be even more so in future years. The Bureau of the Census estimates that by the year 2050, non-Hispanic whites will constitute 56 percent of the U.S. population, versus 76 percent in 1990; people of Hispanic origin will be 20 percent of the population in 2050, versus 9 percent in 1990; and the proportion of blacks will grow from 12 to 14 percent over the same interval (Day, 1993). Similarly, some projections suggest that non-white individuals will be the majority in as many as 53 of America's largest cities only 5 years from now, by the year 2000 (Nestor, 1991). The full impact of such diversity is not just a promise for the future, however. School districts in some sections of the country already report that their enrolled children represent many different language groups. One school in suburban Virginia claims that there are more than 36 language groups represented in its student population.

Even the terms used to describe the growing diversity of the United States—Asian/Pacific Islander, Middle Eastern, or Hispanic/Latino—fail to capture the full complexity. For example, Asian/Pacific Islanders include Laotians, Cambodians, Vietnamese, Hawaiians, Filipinos, Samoans, Guamanians, Japanese, Chinese, Koreans, and others as well. Moreover, in assessing ethnic, racial, and cultural diversity, it is important to distinguish recent immigrants, such as the majority of Southeast Asians now in the United

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

States, from native-born Americans such as the vast majority of black Americans.

This cultural and ethnic diversity is reflected in widely varying knowledge about and attitudes toward contraception and fertility control. For example, some immigrants arrive in the United States from countries whose systems of family planning services are arguably better organized than those here and whose range of available contraceptive methods is broader. Some bring with them rich traditions of folk medicine (such as reliance on herbal medicines and various folk remedies and use of neighborhood practitioners rather than doctors for health care) that do not always blend easily with U.S. approaches to medicine in general or contraception in particular. Some contraceptive methods available in the United States may be unfamiliar to recent immigrants, and the health care system that one must negotiate in the United States to obtain the more effective methods is certainly different, and often more complicated and inaccessible, than systems in the immigrants' countries of origin. Contraception especially may be associated with images and practices that limit its acceptability. For example, in Thailand, condom use is associated with a vigorous prostitution industry in that country, which may mean that efforts in the United States to encourage greater condom use might be resisted by recent Thai immigrants (Healthy Mothers, Healthy Babies Coalition, 1993). For illegal immigrants, the task of securing contraception may be further complicated because of their general inability to use such programs as Medicaid to help finance primary health care, including contraceptive services.

Religious and Political Diversity

As fundamental human behaviors, sexuality and family formation represent legitimate areas of concern for most organized religions. Thus, the moral or ethical principles expounded by religious leaders include such issues as the appropriate age of onset of sexual activity, the regulation of non-marital sexual activity, contraception and abortion, appropriate partners, rituals for recognition of marital unions, and responsibilities and obligations for child rearing. As a country historically considered a refuge for those experiencing religious persecution, the United States is characterized by a large number of religious groups quite heterogeneous as to their principles and practices and the historical antecedents of their beliefs.

Despite the sometimes quite ancient lineage of these principles and prescriptions, the current entanglement of religious and political groups over issues of sexuality and contraception in the United States reflects a relatively recent effort of religious groups to adapt to events coming to prominence largely in this century (D'Antonio, 1994). As discussed elsewhere in this report, these events include the development of effective and reliable means of contraception,

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

wider access to safe abortion, a broader and often conflicting array of sources of information on sexual behavior and mores including the media and sexuality education provided in public schools, and an overt recognition of and pressure to accept sexual activities and alternate family configurations not consonant with traditional religious teachings.

In addressing the current overlap of religious doctrine and political ideology, it is helpful to consider several separate dimensions, including the appropriate locus for transmission of information and values regarding sexual behavior and family function, the use of contraception both within and outside of marriage, the increased public visibility and wider availability of abortion, the extent to which individuals adhere to the official positions of their religious, and the use of political strategies to assert religious and philosophical positions.

Most organized religions transmit values through an alliance with the family, both through formal instruction during or in conjunction with religious services and through modeling of behavior by the family. This traditional mode of transmission has been complicated by the availability of alternative sources of information, especially media.

In response to persistently high rates of teenage pregnancy, and more recently the spread of HIV, efforts have been undertaken to provide information and more appropriate models of behavior through the schools. Although most organized religions support such efforts, some individuals perceive the information and values to run counter to their own religious principles. They view these efforts as encouraging premature sexual activity and sexual activity outside the bounds of formally approved unions. Hence, such efforts are perceived as undermining traditional family values.

In contrast to issues surrounding the transmission of values that generally involves custom rather than formal principles, many organized religions have formal principles dealing with contraception and abortion. Most religions encourage responsible procreation within the confines of marital unions. Most did not, however, have strong moral or ethical traditions regarding contraception and abortion until this century, and there is only a very limited scriptural background on these issues. In Judeo-Christian traditions, only one Biblical passage can be construed as dealing with contraception (and that interpretation is controversial), and the Koran does not have any clear-cut teaching on this topic. Thus, most religious traditions prior to this century reflected the teachings of religious scholars, often in response to specific questions, events, or heresies. Until this century, most Christian scholars condemned contraception and abortion, with more variability within the Jewish and Islamic traditions (D'Antonio, 1994).

In the 1930s, however, this situation changed when the mainline Protestant churches in the United States began to approve contraceptive use by married couples and then later to accept abortion. As is well known, the Roman Catholic Church formally forbids the use of any contraceptive techniques other than

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

''natural family planning" or the rhythm method, and any use of abortion for any reason. Other conservative religious groups also proscribe contraception and abortion, including the Lubavitcher Hasidic sect, the Church of Latter Day Saints, and several conservative fundamentalist and evangelical groups (Carlson, 1994; D'Antonio, 1994).

Regardless of the formal religious positions on sexual activity and control of fertility, substantial variation in practice occurs among those belonging to specific religious groups. The most dramatic example is the disparity between the position of the Catholic Church and most of its American members regarding contraceptive use. Despite the Church's clear stand against artificial means of birth control, most Catholic women and couples in the United States use a wide variety of contraceptive methods; 75 percent of white Catholic couples practice contraception, and among those couples, 63 percent use sterilization or oral contraceptives (Goldscheider and Mosher, 1991). Not surprisingly, the major predictor of personal practice is the degree of "religiosity," that is, the degree to which religion is seen as important and to which individuals observe other aspects of their religion (D'Antonio, 1994).

The considerable diversity of opinion among organized religions and the considerable diversity of personal practice among the membership of these religions, do not, by themselves, explain the vehemence of the current political debate on abortion and family values. The major change over the past decade has been the emphasis on conservative forms of family values and a coalescence of Catholics and the conservative elements within many Protestant denominations into politically active groups. Although certainly initiated among Roman Catholics, this movement now includes a large number of conservative Protestants who share a common vision of a threat to traditional family values. Furthermore, although the National Conference of Catholic Bishops has certainly played a seminal role in bringing its resources to political activity, evangelical Protestant groups such as the Moral Majority are equally committed and also bring substantial resources (Carlson, 1994).

Even though people and financing are important elements in attaining political power, another element also contributes to the current political climate. Blendon and colleagues (1993) report that the majority of Americans support the availability of abortion, but they do so conditionally and do not consider it their most important political issue. By contrast, those who strongly oppose abortion view it as a top priority and often vote for candidates on the basis of their expressed positions on abortion. In exploring this phenomenon more carefully, Blendon and colleagues (1993) found that there is no evidence that groups who strongly support abortion vote with the same single-issue orientation as do those who strongly oppose abortion. They also found that the tendency to view political issues through the lens of abortion is directly related to an individual's participation in his or her religion (or to their degree of "religiosity"). One noteworthy aspect of the continuing opposition to abortion is that some of those

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

who strongly oppose abortion are increasingly engaged in aggressive and organized political activity at all levels of government with abortion as their major, but no longer their sole, focus. This issue is addressed directly later in this chapter under the heading "Opposition to Abortion." The expansion of opposition to abortion into opposition to other aspects of reproductive health, especially contraception and family planning, is a puzzling and distressing development, inasmuch as contraception helps to reduce the need for abortion by reducing the occurrence of unintended pregnancies in the first place.

In summary, the availability of effective contraception and abortion and the broader range of sexual behavior considered acceptable in many groups in the United States present a challenge to those espousing traditional family values. Although the majority of Americans profess relatively tolerant attitudes, there is no single shared ethic about what constitutes appropriate family structures or sexual behavior. In response to what is perceived as a threatening liberalization of sexual behavior, conservative elements of many religious denominations have joined in a common cause to protect what are defined as traditional values. The political controversy, in contrast to the moral controversy, reflects the fact that these groups are willing to use the resources of their religious groups for campaigning and lobbying, and they represent single-issue constituencies voting solely on the issues of abortion and family values. Participation in such political activity is less a function of formal religious affiliation than of degree of attachment to religion or religiosity (D'Antonio, 1994).1

Conflicting Views About Sexuality

A particularly provocative explanation for the patterns of contraceptive misuse and nonuse (and therefore unintended pregnancy) seen in the United States is that American culture embraces conflicting views and attitudes toward sexual behavior, and that this underlying inconsistency impedes discussion about, and careful use of, contraception (Reiss, 1991). As Rhode (1993–1994:657) has said so bluntly, "Few if any societies exhibit a more perverse combination of permissiveness and prudishness in their treatment of sexual issues." This reluctance—this "prudishness," it is suggested—makes it difficult to disseminate clear, accurate information about contraception, which in turn may limit contraceptive use. Advocates of this perspective cite a wide variety of data, noted below, to support this point of view.

The first is that the Victorian ideal of coitus only within marriage and with only one partner lingers in the American consciousness, despite the fact that

1  

Appendix B presents additional historical perspectives on the interaction of religion and contraception.

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

patterns of sexual activity now bear little if any resemblance to that bygone era. As noted earlier, the age of first intercourse has steadily dropped, and the image of virginity until the time of marriage—often a fiction in part—is now significantly out of line with current American practices. For example, among women who turned age 20 between 1985 and 1987, almost three-fourths (73 percent) had had intercourse before marriage and before turning age 20 (The Alan Guttmacher Institute, 1994). But even in the face of large numbers of people having nonmarital sex at all ages and with more than one partner, there is still appreciable support for virginity if one is not married (Haffner, 1994). In a study undertaken by Klassen and colleagues (1989), for example, half of the adult respondents reported that they disapproved of adult women having nonmarital sex with a partner they love, and 41 percent disapproved of men doing so.

There are other examples of the mismatch between image and reality as well. Sexual activity in late adolescence has become increasingly common in recent years (Laumann et al., 1944). In the late 1960s, for example, about 55 percent of boys and 35 percent of girls had had intercourse by the age of 18; by the late 1980s, these figures had increased to 73 percent for boys and 56 percent for girls (The Alan Guttmacher Institute, 1994). Nonetheless, a majority of adults disapprove of unmarried teenagers having sexual intercourse (Haffner, 1994). Moreover, although three-fourths of adults believe that unmarried teenagers should have access to contraception, and almost all would want their children to use contraception if the children were sexually involved (Gallup Organization, 1985; Timberlake and Carpenter, 1990), only a third of parents who have talked about sex with their children say that they have included any discussion about contraception (Klassen et al., 1989). Such data suggest that opinions and feelings about sexual behavior may not fit comfortably with contemporary reality (particularly as regards adolescents)—a dynamic that may well limit the ability of individuals and communities to communicate clearly about numerous sexual topics, including ways to reduce unintended pregnancy.

The Media

Observers of the print and electronic media are especially persuasive in suggesting that mixed messages regarding sex and contraception dominate these pervasive forms of communication, and that the prudishness that Rhode (1993–1994) has referred to impedes clear communication about contraception especially. On the one hand, popular American media (network programming, music videos, advertising, etc.) are filled with sexual material; on the other hand, there is a noted absence of equal attention to contraception, responsible personal behavior, and values in sexual expression. The United States has, in effect, a media culture that glorifies sexual activity (especially illicit, romantic

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

sex between unmarried people), but is squeamish about contraception. McAnarney and Hendee (1989:78) note, "The print and electronic media are filled with seductive messages, yet [Americans] are given little support or assistance in understanding sexual feelings, defining responsible sexual behavior, and learning respect for themselves and for others."

That the media are saturated with sexual material is incontestable. A 1991 study of sexual behaviors on network prime time television (i.e., ABC, CBS, NBC, and Fox) found an average of 10 instances of "sexual behavior" per hour (Lowry and Shidler, 1993). Given that a full 98 percent of American households have a television, many more than one, and that 71 percent of U.S. households are tuned in to a network television program during prime time, the exposure level is clearly very high (Brown and Steele, 1994). Although the overall prevalence of sexual material had declined slightly since a similar study was conducted 4 years earlier, in 1987, decreases in portrayals of prostitution and physical suggestiveness (displays of the body without touching) were almost offset by increases in portrayals of heterosexual intercourse (e.g., mentions or allusions to intercourse, as well as suggestive or actual images). Such portrayals on television increased by 84 percent between 1987 and 1991, from 1.8 to 3.3 behaviors per hour (Lowry and Shidler, 1993). Moreover, the promotional messages for other prime-time programs that surround regular programming include even higher rates of sexual behavior. Lowry and Shidler conclude that the networks "clearly are using sex as bait in promos to attempt to increase their ratings." When the sexual behavior in promos is added, the rate of sexual behaviors per hour increases from about 10 to more than 15 (Lowry and Shidler, 1993:635).

With regard to cable television, videocassettes, music rock videos, and movies, the picture is similar. For example, "adult programming" (i.e., X-rated content designed specifically to portray explicit sexual behavior) is cable television's fastest growing segment (Kaplan, 1992). With the advent of a fiber optic infrastructure, a projected 500 channels are expected to include even more such programming. The videocassette recorder (VCR) also provides greater access to sexually explicit material. In 1993 two of the most frequently purchased videos featured Playboy centerfold Jessica Hahn and the "Playmate of the Year" (Billboard Magazine, 1994). Moreover, according to recent content analyses, sex is more frequent and more explicit in movies than in any other medium. Virtually every R-rated film contains at least one nude scene, and some favorites, such as Fast Times at Ridgemont High and Porky's, contain as many as 15 instances of sexual intercourse in less than 2 hours (Greenberg et al., 1993). Despite the R-rating that supposedly restricts viewing to people over 18 unless accompanied by an adult, two-thirds of a sample of high school students in Michigan reported that they were allowed to rent or watch any VCR movie

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

they wanted, and the movies they most frequently viewed were R-rated (Buerkel-Rothfuss et al., 1993).

Such sexual enticement is not balanced by or accompanied by clear messages about avoiding unintended pregnancy or sexually transmitted diseases (STDs) or about managing sexual activity in a safe, caring, and healthy manner. For example, few television programs ever mention the adverse consequences that may result from having sex—rates of mention of pregnancy or disease declined to about one per 4 hours of programming between 1987 and 1991. Thus, a typical viewer would see about 25 instances of sexual behavior for every 1 instance of preventive behavior or comment. Even then, the message may not be constructive—all of the references to STDs coded in the Lowry and Shidler study, for example, were in a joking context (Lowry and Shidler, 1993).

The issue of contraceptive advertising on television brings the mixed message issue into sharp relief. Despite the high level of sexual activity in television programming, as just described, the major national networks have adopted the position that contraceptive advertising will not be accepted, although there is more receptivity on cable and independent stations, and some local affiliates as well, mainly to messages about condoms. Lebow (1994) reports, for example, that ABC feels that in catering to a mass audience, contraceptive advertising would be controversial and offend the moral and ethical tastes of a good part of its audience, and the Fox network says that it will possibly accept condom advertisements only if they are designed to prevent disease; messages about preventing unintended pregnancy remain off limits. Similar views constrain the airing of public service announcements (PSAs) that offer general information about contraception, although there were some brief periods of receptivity to selected PSAs developed by the Planned Parenthood Federation of America and the American College of Obstetricians and Gynecologists. By contrast, the print media have been more accepting of contraceptive advertising. Advertisements for birth control now routinely appear in many magazines and some, though not all, newspapers (Lipman, 1986). Interestingly, public opinion appears to favor contraceptive advertising through the media. A Roper organization survey in 1991 found that two-thirds of Americans age 18 or older supported the airing of contraceptive advertisements (Lebow, 1994).2

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It is important to note that television advertising of such prescription-based methods as oral contraceptives faces restrictions from the Food and Drug Administration, which requires that complete listings of risks and side effects accompany any advertisement—a requirement that is not practical for television in particular. Recently, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Medical Association, and others have urged that new policies and guidelines be developed to allow direct advertising to consumers of these effective methods.

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

Commercial advertisers may be limited in their ability—and sometimes their willingness—to promote contraception directly, but they often use sexual appeals to sell their products. A study of 4,294 network television commercials found that 1 of every 3.8 commercials includes some type of attractiveness-based message (Downs and Harrison, 1985). Although most advertisements do not directly model sexual intercourse, they help set the stage for sexual behavior by promoting the importance of beautiful bodies and products that enhance attractiveness to the opposite sex.

In sum, all forms of mass media, from prime-time television to music videos, magazines, advertising, and the news media, include vivid portrayals of sexual behavior. Sexual activity is frequent and most often engaged in by unmarried partners who rarely appear to use contraception, yet rarely get pregnant.

Does exposure to such content contribute to early or unprotected sexual intercourse with multiple partners and high rates of unintended pregnancies among both adolescents and adults? At this point, more is known about what is in the media and how much people are exposed to it, than is known about how the media's content is interpreted or how it affects sexual behavior. According to classic social scientific methods, an ideal test of the effect of sexual content in the media would involve either randomized assignment to different media diets or longitudinal surveys. Such studies would establish whether media exposure or the specific behaviors of interest came first. Unfortunately, the perceived sensitivity of sex as a topic and a focus on adolescents and television to the exclusion of other age groups and other media have restricted the kind of research that has been done. Only a handful of studies has attempted to link exposure to such measures as audience beliefs, attitudes, or subsequent behavior. Moreover, a number of factors, such as gender, cultural background, developmental stage, and prior sexual experience, influence what media are attended to and how images are interpreted. It is reasonable to expect, for example, that individuals who are more sexually active and people who are anticipating having sex will see media content about sexuality as more relevant and thus seek it out. The most likely scenario is that the media's influence is cyclical—individuals who are interested in sex begin to notice sexual messages in the media, may be influenced by and act on them, and then may attend to such messages more in the future (Brown, 1993).

In a comprehensive review of the literature in this area covering both correlational studies as well as experimental studies, Brown and Steele (1994:16) concluded that "the few existing studies consistently point to a relationship between exposure to sexual content and sexual beliefs, attitudes, and behaviors." For example, studies of adolescents have found that heavy television viewing is predictive of negative attitudes toward remaining a virgin. Two studies have found correlations between watching high doses of "sexy" television and early

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

initiation of sexual intercourse (Brown and Newcomer, 1991; Peterson et al., 1991).

There probably are useful lessons to be learned from reviewing the large literature on the role of the media in violent behavior. Violence and sex have been used throughout the short history of television, and for a longer time in other media, to attract attention and arouse viewers, keeping them interested enough so that they will attend to the advertising. Both violence and sex are frequently and positively portrayed. Further studies of the impact of the media on sexual behavior may well find patterns of effects similar to those established for violence. More than 1,000 studies have consistently found small positive relationships between exposure to violent content in the visual media (primarily television and movies) and subsequent aggressive and antisocial behavior (Comstock and Strasburger, 1993). Both the 1972 Surgeon General's Report and a 1982 report from the National Institute of Mental Health concluded that exposure to violence in the media can increase aggressive behavior in young people (Brown and Steele, 1994).

International Comparisons

Cross-national comparisons give added weight to the idea that America's conflicted views and values regarding sexuality contribute to unintended pregnancy. Noting, for example, that in Denmark the proportion of pregnancies estimated to be unintended is far lower than that in the United States, David and colleagues (1990:3) have commented:

In Denmark, as in other Nordic countries, the approach to sex is pragmatic, not moralistic. Most Danes deem sexuality as a natural and normal component of a healthy life, similar to eating and sleeping, for which individuals must assume personal responsibility through effective contraception to prevent unintended pregnancies. Sexuality and contraception are openly discussed in the media and the location of contraceptive counselling centers is advertised. Information is provided to children at an early age. There is an entrenched national consensus to limit childbearing to wanted pregnancies.

A different set of investigators (Jones et al., 1986) expressed a similar view after studying the factors associated with varying patterns of teenage fertility in the United States and several other industrialized countries. One of their conclusions was that, compared with several other countries with lower rates of teenage childbearing, the United States is far less open about sexuality in general. The authors refer to the "underlying puritanical values" in the United States as limiting effective, easy communication about the importance of using

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

contraception unless pregnancy is actively sought, how specific methods work and what their benefits and risks are, and where to obtain them.

The picture that these various data sets present is troubling: a country that has left its Victorian, perhaps puritanical, past far behind but is not comfortable with present day sexual practices; and a popular culture that, paradoxically, glorifies sexual expression—especially illicit romantic sex between perfectly formed, unmarried young people—but cannot accompany this fascination with plentiful messages of health promotion and disease prevention, including the use of contraception to avoid unintended pregnancy.

Economic Influences on Fertility

A large and rich body of research has probed the relationship of various economic factors to fertility. Although other sections of this report address some of these issues, such as financial barriers to contraception (Chapter 5) and publicly financed family planning programs (Chapter 8), several additional topics merit highlighting. Federal and state legislators are particularly interested in the impact on fertility of such welfare programs as Aid to Families with Dependent Children (AFDC), but this section will first note a broader range of economic factors in the United States in order to provide a perspective on the welfare issue. It examines whether fertility is influenced by (1) nationwide trends in prosperity, (2) present or future individual or family financial status, (3) whether a woman is employed, and (4) whether the woman or the family receives welfare.

In trying to understand the influence of economic factors on fertility, a number of analysts have focused on the Depression especially. A glance at fertility rates over time indicates clearly that the rates declined during the Great Depression, suggesting that economic stress may decrease childbearing especially. However, since fertility rates were already declining before the Depression, most analysts believe that although the Depression may have increased this trend and made it longer, the Depression itself was not responsible for most of the decline. The Depression was closely followed by World War II, which disrupted family formation, so the decline continued, despite greater economic prosperity. Fertility rates rose sharply after the end of the war, creating the Baby Boom, and then continued their pre-Depression decline, despite the continued post-war economic expansion (Klerman, 1994).

In terms of present financial status, conventional economic theory suggests that fertility should increase with family income if children are a valued commodity. This theory is not supported by trends in the United States and other industrialized nations. There are several reasons for this. Infant and child mortality has declined markedly such that it is no longer necessary to have many children in order to ensure that a few live to adulthood. Moreover, although

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

children may still be valued, they no longer add to family income by working in the fields or in factories. They are not an economic asset; in fact they are a major liability. Thus, particularly for families in the middle- and high-income brackets with high, and expensive, expectations for their children, larger incomes might be associated with lower rates of fertility. The empirical evidence in this area, as in the others presented in this section, is mixed.

In terms of future financial status, a major question is why adolescents have children despite the fact that early childbearing is associated with limited income later in life. Early childbearing may occur because adolescents vaguely realize what researchers are now confirming, that is, that the association is probably not entirely causal (Chapter 3). An adolescent's future financial situation may be bleak even if she delays childbearing because women who become pregnant as adolescents are more likely than those who do not to come from poor families, and growing up in a poor family is probably the major reason why many women who begin childbearing in their teens are poor as adults. The magnitude of the independent contribution of a teenage birth to a girl's financial status as an adult is controversial, but it is probably less than her family's initial economic status (Hoffman et al., 1993). Adolescents may not wish to forego their present enjoyment of children for the limited possibility that their financial status may be brighter if they wait. This may explain why even programs that suggest life options other than early parenthood often fail to prevent first pregnancies among adolescents and why programs that provide job skills training and that assist with employment for those who are already mothers seldom succeed in having a long-term impact on subsequent fertility (Maynard, 1994). The influences of poor neighborhoods, inadequate schools, and broken families, themselves caused in part by economic trends, may be too strong to be overcome by short-term programs, even those based on improving adolescents' future economic status. This issue is also addressed in Chapter 6.

For some women employment is an option, but for many it is a necessity. Among those for whom it is an option, choosing a career may lead to the postponement of childbearing, limiting of family size, or foregoing childbearing entirely. Women who work out of necessity may also try to limit the number of children they bear, since they would lose time from work at least immediately before and after the pregnancy and, in the child's early years, might need to pay for child care. There is some support for the theory that higher market wage opportunities for women reduce fertility (Schultz, 1994).

AFDC and Other Transfer Programs

A large literature has addressed the influence of the major income transfer programs in the United States (especially AFDC, Medicaid, and the Food Stamp program) on marriage, the labor supply, household structure, pregnancy and

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

fertility of low-income women and households. Very little of this literature, however, has been concerned with the linkages between such programs and unintended pregnancy, which is the focus of this report.

Potential Influences

From a theoretical point of view, there are at least three kinds of program effects that deserve consideration, two of these effects being direct and the other somewhat indirect. First, it is at least conceivable that for some women the presence of AFDC, which provides a thin cushion of economic support in the event of a birth, may be seen as reducing the full costs of such a birth. In so doing, the program may thereby reduce the degree of contraceptive vigilance maintained by the woman and also reduce the likelihood of abortion in the event of an unintended pregnancy. In theory, any income support program could have such an effect, so long as program eligibility is defined in terms of family size relative to income and total benefits increase with family size. Thus, the Food Stamp program, in which roughly 1 in 10 Americans participates, might conceivably have an influence on contraceptive use and unintended pregnancy. The case of AFDC is somewhat more complicated, in that receipt of benefits is made conditional on family structure—that is, on the absence of a spouse—although in the 1980s many states implemented the so-called "AFDC-UP" version of the program, which allows benefits to be distributed even if an (unemployed) spouse is present.

A second potential influence comes about because of the specific financing provisions embedded in the Medicaid program and the close ties between Medicaid eligibility and participation in AFDC. Medicaid eligibility is an important avenue to free or highly subsidized contraceptive services for many poor women and in the past was also a source of financing for some abortions (see Jackson and Klerman, 1994). To the degree that contraceptive prices act as barriers to contraceptive access for poor women, the Medicaid program should improve contraceptive access and thereby reduce the risk of unintended pregnancy. To the degree that Medicaid and AFDC are tied, however, these contraceptive subsidies are implicitly conditioned on family structure as well as income, so that the implied change in risks of unintended pregnancy would be circumscribed and limited to female-headed households.

A third and somewhat indirect link is that, particularly in those states that do not implement AFDC-UP provisions, AFDC establishes a set of incentives that collectively discourage marriage and perhaps encourage marital dissolution. In particular, welfare rules and regulations that made receipt of benefits contingent on there being no man in the house may have had the effect of pushing men out of families. Unmarried women are less likely than married women to intend to become pregnant, other things being equal. Thus, by

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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discouraging marriage, AFDC may, in effect, increase the number and percentage of women who are exposed to the risk of an unintended pregnancy, although there is very little scholarship on this issue.

Empirical Findings

As was noted above, unintended pregnancy has not emerged as a major theme or focus of research in the literature on AFDC and other income transfer programs. One exception to this is in the area of teenage childbearing, which is disproportionately the result of unintended pregnancy, and some of the recent literature on abortion is also relevant (Jackson and Klerman, 1994).

In Moffitt's (1992) recent and authoritative review, the literature on the effects of AFDC on marriage, marital dissolution, and female headship was divided into a set of studies pertaining to the period of the 1970s and earlier, and a more recent literature dealing with the experiences of the 1980s. The time period of a study is important, since the real value of AFDC benefits declined sharply after 1967 (Moffitt 1992:Figure 1) and by 1985 the level of real benefits had fallen below what was available in 1960. These declines in AFDC benefits were largely offset by expansions in the Food Stamp and Medicaid programs; for the former, at least, eligibility does not depend on the absence of a male spouse.

With respect to marriage and female headship, the earlier literature produced no clear consensus on either AFDC or total transfer program effects. The empirical findings from the 1970s displayed great diversity and inconsistency across studies (see Groenveld et al., 1983). According to Moffitt, stronger and somewhat more consistent program effects are often estimated for the 1980s, suggesting that income transfer programs do have a discernible effect on female headship (Ellwood and Bane, 1985) and remarriage (Duncan and Hoffman, 1990). Even these effects, however, are small in magnitude. Moffitt (1992:31) writes that ''none of the studies finds effects sufficiently large to explain, for example, the increase in female headship in the late 1960s and early 1970s. If this result continues to hold up, research in this area would better direct itself toward a search for the other causes presumably generating the increases in female headship."

With regard to effects on childbearing (which is not separated into its intended and unintended components), the findings of the recent literature remain weak and inconsistent. Ellwood and Bane (1985) and Duncan and Hoffman (1990) find no significant effects. Plotnick (1990) and Lundberg and Plotnick (1990), by contrast, find significant positive influences of benefit levels on non-marital childbearing, but only for whites. In their preliminary work on teens, Jackson and Klerman (1994) report that AFDC benefit levels seem to exert a modest positive influence on non-marital fertility rates measured at the state

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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level. The authors are concerned with the possibility that the apparent influence is not causal in nature but rather reflects other factors that could not be measured. Preliminary estimates also suggest that Mediciaid funding for abortion—now provided by a few states without accompanying federal financing—does not appear to influence teen nonmarital fertility rates.

In summary, the empirical literature does not lend support to the popular perception that AFDC and other income transfer programs exert an important influence on non-marital fertility. The literature suggests that these programs may well affect female headship, however, although there are other factors, not yet well-understood, that appear to be much more important.

Racism

As noted earlier in this report, the proportion of births derived from unintended pregnancies is higher among black Americans than among other racial groups, and there are also data suggesting that rates of unintended pregnancy are higher as well. There are undoubtedly many explanations for these observed differences. For example, to the extent that blacks are disproportionately poor, the problems of access to contraception and lack of health care that are associated with poverty fall particularly heavily on this group. Similarly, the greater risk of poor quality care faced by black women in two important components of women's health—hysterectomy (Kjerulff et al., 1993) and prenatal care (Kogan et al., 1994)–raises the possibility that in the field of contraceptive services, too, black women may be at risk of less than adequate care. Another set of factors that may help to account for the differences is based in the long and complicated relationship of black Americans to contraception and the birth control movement generally.

In summarizing this important history, Gamble and Houck (1994) have noted that from 1920 through 1945 the birth control movement was generally supported among blacks because it meshed with their political and social efforts to improve both the health and economic status of the black community. By allowing women to space their children, birth control was seen as leading to better maternal health, and better maternal health was seen as a way to decrease infant mortality. Furthermore, with fewer children families would have more resources to care for their offspring. Thus, birth control could be seen as a strategy to shed the burden of poverty that kept black people at the bottom of the social strata. Black proponents of birth control believed that birth control translated directly into material improvement in terms of housing conditions, food, clothing, and educational opportunities. Similarly, Rodrique wrote (1991:26, 48): "The black community in general had a … broad, political agenda for contraceptive use. Afro-Americans saw birth control as one means to attain improved health, and having secured that, equal rights and social

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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justice." A controlled birth rate would be a "step toward independence and greater power" and would allow more resources to be used for the advancement of the entire group.

This is not to say that all members of the black community supported birth control efforts at that time; in 1925, for example, Dean Kelly Miller of Howard University expressed concern that black women were having fewer children and feared that the result would be race suicide (Rogers, 1925). During this time, concerns began to develop that have continued to influence the attitudes of many black Americans toward birth control programs:

The question of who is to control the programs and whose objectives are they to meet clearly surfaced during this period. … Historical analysis … illuminates the importance of seeking assistance from institutions that African Americans had established themselves. African Americans may perceive their needs in a different fashion than other segments of society may view them and may shape activities accordingly [Gamble and Houck, 1994:18].

Two additional issues surfaced in the postwar period. These issues, like the control and participation issue noted directly above, produced a more complicated picture of the relationship of the black community to contraception: the divisive entanglement of race, welfare, and birth control; and the issue of contraception as racial genocide. These issues remain current and painful, as the contemporary discussion of welfare reform in particular makes clear.

Race, Welfare, and Birth Control

Gamble and Houck (1994) observe that taxpayer resistance to welfare expenditures grew after World War II. The disproportionate number of blacks who received public assistance may have been the primary factor for the opposition. In response to public demands, several state legislators introduced bills throughout the 1950s and 1960s to institute punitive sterilization for unwed mothers on welfare. Black women were frequently the targets of the legislation. For example, in 1958 Mississippi State Representative David H. Glass sponsored the bill "An Act to Discourage Immorality of Unmarried Females by Providing for Sterilization of the Unwed Mother Under Conditions of the Act; and for Related Purposes." Glass did not conceal the impetus behind the proposed legislation. He asserted,

During the calendar year 1957, there were born out of wedlock in Mississippi, more than seven thousand Negro children. … The Negro woman because of child welfare assistance [is] making it a business, in some cases, of giving birth

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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to illegitimate children. … The purpose of my bill was to try to stop, slow down, such traffic at its source [Solinger, 1992:41].

Glass's bill was not enacted. However, the sentiment that it represented did not die with it, as evidenced by legislative initiatives with similar intent in other states (all of which were unsuccessful).

The entanglement between welfare and contraception continued after the introduction of oral contraceptives in the 1960s. In 1960, for example, the welfare and health departments of Mecklenburg County, North Carolina, launched a joint program to provide contraceptive services to women on public assistance. Four years later, the county welfare director concluded that the program had proven to be extremely cost-effective. He reported that for every $! spent on a package of birth control pills the county saved $25 in welfare costs; he further estimated that the county had saved $250,000 in Aid to Dependent Children grants (Shepherd, 1964). Other localities moved to initiate programs with the hopes of duplicating the Mecklenburg County results. Despite some opposition from religious organizations, most notably the Catholic Church, by 1967, 33 states provided contraceptive services for women on welfare (Harting et al., 1969; Morrison, 1965; Shepherd, 1964).

Black Americans called attention to the potential for coercion in the implementation of the contraceptive programs. Although rules mandated that participation in government-subsidized family planning programs should be voluntary, stories soon surfaced about case workers who had informed women that their public assistance depended on their use of birth control. Critics argued that the specter of governmental coercion made birth control appear to be an obligation for poor women rather than a matter of personal choice.

The entanglement of contraception in matters of welfare policy continued with the development of Norplant (Rosenfield et al., 1991). Since the 1990 U.S. Food and Drug Administration approval of Norplant, legislation promoting its use has been proposed in several state legislatures as a way to decrease welfare costs and to combat poverty. In February 1990, for example, Kansas State Representative Kerry Patrick proposed legislation to pay welfare mothers $500 to use Norplant. Insertion would also be covered by the state, plus the women would receive free annual checkups and $50 for each year that they kept the implant. Kerry proclaimed that "the creation of this program has the potential to save the taxpayers millions of their hard-earned dollars" (Rees, 1991:16). Similarly, in Louisiana, State Representative David Duke proposed legislation that would offer women on welfare $100 a year to use Norplant (Rees, 1991). During the first 6 months of 1993, legislation introduced in seven states would have established incentives for welfare recipients to use Norplant or would have mandated decreased welfare benefits for women who refused to use it. None of these bills passed, but activities to link birth control with state welfare policies continue (Lewin, 1991).

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Members of the black community, including health activists, social scientists, and ethicists have harshly criticized these efforts (see, for example, Scott, 1992). They have pointed out the potential coercion inherent in these efforts. In addition, they have decried efforts to narrowly define the causes of poverty. As one observer has noted, "The solution to poverty is not combating fertility. It's creating opportunities" (Rodriguez, 1991).

Genocide

As suggested by the welfare–contraception entanglement, probing the black community's views on genocide is also central to understanding its attitudes toward birth control. Although members of the black community expressed some concerns about birth control and race suicide during the 1930s and 1940s, development of governmental family planning programs in the 1960s and 1970s fueled renewed concerns about the links between birth control and genocide. Black Americans responded to such programs with suspicion, ambivalence, skepticism, and, at times, open hostility. Some black people contended that they were targets of a government policy that was "more concerned about stopping babies than stopping poverty." The objectives of the initiatives, they argued, appeared to be to control the number of poor and minority people rather than to attack their social and economic conditions. Blacks pointed out that other antipoverty measures such as education, housing, comprehensive health care, and employment did not receive the vigorous support from politicians that family planning did. As Malveaux stated (1993:34): "Genocide is often used as a code word for many inequities related to race and reproductive rights—the use of Norplant … forced on poor black women; the unavailability of basic health care for many low-income and working people in our community; [and] the apparent disinterest of pro-choice activists in a broader range of social issues that affect the black community."

A history of coercive sterilization practices against poor women and black women also fueled distrust. In 1968 Douglas Stewart, director of Planned Parenthood's Office of Community Relations, acknowledged the impact of these abuses on black women's acceptance of family planning. He stated,

Many Negro women have told our workers, "There are two kinds of pills—one for white women and one for us … and the one for us causes sterilization." This is a very real fear for some women. Perhaps it's because many of them are from the South where black people have heard instances of unwarranted sterilization by white clinic workers whose attitude seems to be "Let's get the Negro before he's born" (cited in Smith, 1968).

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

In the 1970s numerous reports of sterilization abuses against women of color surfaced. In the 1974 Relf case (Relf v Weinberger), a federal district court found that an estimated 100,000 to 150,000 poor women were sterilized annually under federally-funded programs. Some of these women had been coerced into consenting to the procedure by threats that failure to do so would result in the termination of welfare payments. This historical legacy of distrust profoundly affected black Americans' attitudes toward family planning. Many viewed the increased availability of oral contraceptives not solely as a matter of individual choice but also as a reflection of a government policy to decrease their numbers.

Some black men, many associated with nationalist organizations, have voiced strong opposition to government-sponsored family planning programs, although many black women have not agreed, seeing birth control more as a survival mechanism than as a genocidal tool. The words of Congresswoman Shirley Chisholm (1970:114) reflect this view:

To label family planning and legal abortion programs "genocide" is male rhetoric, for male ears. It falls flat to female listeners and to thoughtful male ones. Women know, and so do many men, that two or three children who are wanted, prepared for, reared amid love and stability, and educated to the limit of their ability will mean more for the future of the black and brown races from which they come than any number of neglected, hungry, ill-housed and ill-clothed youngsters.

However, black women were not blind to the incongruity of the government plan to make contraceptives free and accessible to black communities that lacked basic health care. Black women acknowledged that they had to be vigilant in their acceptance of the government programs.

Vocal allegations of genocide diminished by the mid-1970s, but they have resurfaced in the 1990s. Continuing economic and social problems in portions of the black community, ongoing racism, and the growth of black nationalism have played roles in the resurgence. Charges of genocide have been raised in connection with AIDS, needle exchange programs, and reproductive health issues (see, for example, Cary, 1992; Thomas and Quinn, 1991; Bates, 1990). Turner (1993) underscores why it is important not to dismiss concerns about contraception as genocide. She argues that examining these feelings reveals a great deal about the viewpoints of black Americans. She contends that these views are based in and grow out of deeply felt beliefs held by many minority members that white Americans have historically been and continue to be ambivalent and perhaps hostile to their well-being.

Gamble and Houck (1994:31) conclude: "Historical analysis makes clear why issues surrounding birth control can touch … such high voltage sensitivity among black people. They provoke fears of genocide; they prompt concerns about who should make decisions and control the direction of the African-American

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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community; [and] they expose the perniciousness and tenacity of racial stereotypes." The precise extent to which historical wounds and current injustices affect contraceptive use, misuse, and failure among black Americans is unknown, but there clearly is reason to see a connection—one that is rarely acknowledged candidly in discussions about differing patterns of contraceptive use and unintended pregnancy.

Violence

Violence against women—rape and sexual abuse in particular—may also be associated in several ways with unintended pregnancy, especially among adolescents. Violence against women is increasingly evident and has recently captured the nation's attention as a major public health problem. Current estimates are that as many as 4,000 women die each year from domestic violence (i.e., violence that occurs between partners in an ongoing relationship), and some 4 million are beaten annually by boyfriends or husbands (National Women's Health Resource Center, 1991). The American College of Obstetricians and Gynecologists estimates that one-fourth of American women will be abused by a current or former partner in their lifetime (American College of Obstetricians and Gynecologists, 1989). In addition, various studies estimate that between 4 and 17 percent of women experience violence during pregnancy (Centers for Disease Control and Prevention, 1994). Interestingly, a recent analysis of 1990–1991 data from the Pregnancy Risk Assessment Monitoring System found rates of physical violence against women within the 12 months preceding childbirth to be significantly higher among women with unintended pregnancies than among those with intended ones (Centers for Disease Control and Prevention, 1994).

The incidence of rape appears to be very high, though estimates vary widely. The U.S. Department of Justice suggests that there were between 100,000 and 130,000 rapes in 1990 (National Research Council, 1993); other estimates are substantially higher after attempts are made to correct for underreporting, showing that perhaps as many as 700,000 to 1 million rapes occur annually (Sorenson and Saftlas, 1994; National Victim Center, 1992). Some of this violence against women, including date rape and other forms of nonconsensual sex, has been attributed to the presence of alcohol or substance abuse. Recent data underscore the special vulnerability of very young girls to rape and other forms of nonconsensual sexual contact. A 1992 study from the U.S. Department of Justice found that, in a survey of 11 states and the District of Columbia, half of the women and girls who had been raped were under the age of 18 and 16 percent were under the age of 12 (Bureau of Justice Statistics, 1994).

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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These data on the rape of girls and young women are consistent with the analysis of Moore and colleagues (1989) of the 1987 National Survey of Children, which found that 7 percent of all respondents (men and women aged 18–22) reported that they had experienced at least one episode of non-voluntary sexual intercourse. There were, however, important race and gender differences; for example, white women were more likely than black women to report non-voluntary intercourse before the age of 20 (13 versus 8 percent). That study also demonstrated that if non-voluntary intercourse were eliminated from the sample studied, the age of first intercourse would be appreciably different. At age 14, for example, almost 7 percent of white women reported that they had had intercourse; if, however, one restricts the variable to the first voluntary intercourse, the figure drops to 2.3 percent; for black women, the comparable figures are 9.0 and 6.2 percent. Moore and colleagues (1989) conclude that forced sexual activity is one of the factors contributing to pregnancy among younger adolescents especially, inasmuch as the use of contraception in these circumstances is an unreasonable expectation. "If the prevention of pregnancy … is difficult for adults, the obstacles to rational, prophylactic behavior among children and adolescents exposed to non-voluntary sex seem almost insurmountable" (Moore et al., 1989:114).

Other research confirms the prevalence of non-voluntary sexual activity. Small and Kerns (1993) reported that in a medium-sized city in the Southwest, 21 percent of a large sample of girls (1,149 girls in grades 7, 9, and 11) reported that they had experienced unwanted sexual contact in the preceding year; for the girls in the 11th grade, about half of this unwanted sexual contact was intercourse, whereas for the younger women, unwanted intercourse represented between 25 and 30 percent of the unwanted sexual contacts.

These various data suggest the need for more careful supervision of young adolescent girls especially. Even without knowing what proportion of pregnancies among young adolescents occur during intervals of inadequate supervision, as noted in Chapter 6, it is reasonable to believe that more adequate adult monitoring of adolescents' safety and whereabouts could decrease these alarming figures on nonconsensual sexual activity.

A growing body of research suggests a particularly important connection between unintended pregnancy and sexual abuse. At least three studies have shown that a history of childhood sexual abuse among teenage mothers is common, and given that the majority of pregnancies among teenagers are unintended (Chapter 2), a link between the two is plausible (Boyer and Fine, 1992; Butler and Burton, 1990; Gershenson et al., 1989). Researchers have hypothesized that pregnancy is more likely among those with a history of sexual abuse because sexual victimization can be associated with lower self-esteem, sexual maladjustment, and feelings of powerlessness and hopelessness—feelings that might in turn impede careful use of contraception once sexual activity has

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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begun (Musick, 1993). Boyer and Fine (1992), for example, found strong histories of abuse in their 1988–1992 study of 535 teenage girls who were pregnant or had already given birth; almost 66 percent reported that they had been the subject of sexual abuse. Forty-four percent had been raped, with 30 percent raped two to three times; the average age of first rape was 13.3, with the rapist's average age being 22.6. Of the adolescents who had been raped, 11 percent said that pregnancy had resulted. In comparing those who were pregnant or parenting and had been abused with those who were pregnant or parenting but had not been abused, the abused group was more likely to report use of alcohol or drugs or to have had a partner who used alcohol or drugs at first intercourse as well as at the time that pregnancy occurred (which in turn may interfere with vigilant contraceptive use or be a marker of risk-taking generally; see Chapter 6). The abused group was also more likely to report that they had not wanted to have intercourse at the time that pregnancy occurred, and the mean age of first intercourse was younger than that for the nonabused group (mean age, 13.2 versus 14.5). However, the reported use of contraception at the time that pregnancy occurred was similar in the two groups. The investigators concluded that the link between sexual victimization and adolescent pregnancy is important and under-appreciated and deserves additional research.

These data highlight an additional component of the sexual abuse picture—the evidence that an appreciable portion of the sexual relationships and resulting pregnancies of young adolescent girls are with older males, not peers. For example, using 1988 data from the NSFG and The Alan Guttmacher Institute, Glei (1994) has estimated that among girls who were mothers by the age of 15, 39 percent of the fathers were ages 20–29; for girls who had given birth to a child by age 17, the comparable figure was 53 percent. Although there are no data to measure what portion of such relationships include sexual coercion or violence, the significant age difference suggests an unequal power balance between the parties, which in turn could set the stage for less than voluntary sexual activity. As was recently said at a public meeting on teen pregnancy, "can you really call an unsupervised outing between a 13-year-old girl and a 24-year-old man a 'date'?"

Gender Bias

At least two forms of gender bias have been suggested as contributing to the high proportion of pregnancies that are unintended. The first is that the apparent tolerance for unintended pregnancy in the United States reflects a subtle but powerful underlying attitude that women are expected to have children and that therefore whether a pregnancy is wanted or intended is not particularly important. The second is that the prevailing policy and program emphasis on

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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women as the key figures in contraceptive decision making unjustly and unwisely excludes boys and men.

With regard to the first aspect of gender bias, contemporary feminists argue that there is a systematic undervaluing of women and a lack of attention to their needs, especially in the health sector (Rodriguez-Trias, 1992). They further suggest that the lack of concern generally over unintended pregnancy—and, in particular, the failure to make contraceptive services and information easily available—is but another example of women's second-class status, joining such other public health injustices as the slow-to-surface outrage against violence directed at women (see above), the over-representation of women in the uninsured and underinsured populations (Institute of Medicine, 1992), the failure to include women in selected types of clinical research (Institute of Medicine, 1994), the fragmentation of health services for women (Rosenthal, 1993), their poor receipt of preventive care (Wall Street Journal, 1993), and similar issues described by leaders of the women's health movement (see, for example, Hafner-Eaton, 1993; Zimmerman, 1987). Indeed, many leaders of the women's health movement began their public advocacy around issues of reproductive rights (J. Norsigian, pers. com., 1994), and many of the core issues of that movement remain centered on reproduction—access to contraception and abortion, development of better and safer contraceptive devices, and reducing unintended pregnancy.

Feminists assert that if women cannot control their fertility due to prevailing public policies and attitudes, they cannot control their lives, and moreover, that many of the problems surrounding contraception, abortion, and reproduction are attributable to patriarchal and paternalistic attitudes and policies in this country and elsewhere, based on a male wish and ability to control women. They suggest that the continued occurrence of unintended pregnancy and other reproductive health problems can be traced to the controlling ideologies and practices of male-dominated religions, federal and state laws and regulations, and prevailing cultural traditions that keep women in subservient, relatively powerless roles. This view holds that because men neither become pregnant nor bear children, they are less interested in or sensitive to the many burdens that pregnancy (especially unintended pregnancy) can impose, and therefore are slow to take remedial action. This perspective is consistent with deliberations at the recent United Nations Conference on Population and Development in Cairo—a meeting that focused crisply on the pivotal role that women's status plays in overall social and economic well-being (United Nations, 1994).

The second view—that men have largely been excluded from the family planning movement—is an old observation that has recently received renewed attention. In 1968, for example, Chilman cautioned against organizing family planning education and programs that focus only on women, noting that the limited research available at the time suggested deep male interest in issues of family size and contraception. More recently, an increasing number of meetings,

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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programs, and research have begun to probe the complicated relationship of men to contraception, pregnancy, and parenthood (Edwards, 1994). Some of this increased attention to men undoubtedly derives from the explosion of STDs, including HIV and AIDS, and the fact that one of the best means of preventing the transmission of STDs is through the male use of condoms. Another factor is the recent increase in nonmarital childbearing and the deepening concern over the number of children in the United States, especially black children, who will spend significant portions of their childhood and adolescence in households without fathers. The passage of the Family Support Act of 1988 also focused attention on men and family formation by developing new procedures to establish paternity and to collect child support payments from fathers, regardless of marital status, through the Child Support Enforcement Program. Current welfare reform proposals put even greater emphasis on establishing paternity. Heightened attention to gender bias in many aspects of American life may also be contributing to the increasing interest in the male role in family planning.

Research has also focused attention on men, particularly the accumulating evidence that contraceptive use by women is affected by partner communication and attitudes, as detailed in Chapter 6. Sonenstein and Pleck (1994) have concluded that males are relatively more involved in females' decisions to use female methods than is often realized. As early as 1978, Thompson and Spanier's multivariate analysis in a college sample found that of all the variables examined, male encouragement to use a method of contraception was the strongest predictor of female use of a method.

As a general matter, however, males are at the fringes of the nation's complex system of family planning services, in part because many of the most effective methods of contraception are used by females, and also because of the simple biological fact that pregnancy occurs in women, not men, and therefore women have the greatest self-interest in managing contraception. Very few males turn to family planning clinics or health personnel for contraceptive supplies. In the 1991 follow-up interviews for the National Survey of Adolescent Males, for example, only 3 percent of all 17- to 21-year-old males—but 9 percent of black males—indicated that they had obtained the last condom they used from a clinic or a physician (Sonenstein and Pleck, 1994).

These low rates of clinic participation by males conform with evidence provided by a recent survey of 421 publicly funded family planning clinics. Eighty-seven percent of these clinics' administrators reported serving no male clients (31 percent) or fewer than 10 percent male clients (56 percent) (Burt et al., 1994). Across all the clinics, the average proportion of male clients served was approximately 6 percent. Similarly, it is estimated that 2 percent of Title X program clients in 1991 and 2 percent of Medicaid family planning recipients in 1990 were male (Ku, 1993). Since Medicaid eligibility is based primarily on participation in AFDC or recent program expansions to low-income pregnant women, it is not surprising that few males receive family planning services

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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through Medicaid. However, there is nothing in Title X law that forbids the use of these funds for men (Danielson, 1988).

Even though most family planning clinics report serving few male clients, they do not ignore condoms. Virtually all of the clinics surveyed by Burt et al. (1994)—99.6 percent—reported that they provide condoms, but it was more often for supplementary protection, not as the primary method. In fact, a recent survey revealed that three-fourths of family planning clinic workers say that they encourage most or all of their clients to use condoms regardless of the primary method chosen for contraception. Although many try, however, only one-fifth think that they are successful with most or all of their clients. Some family planning clinics also do outreach to male clients. Thirty percent of the clinics are reported by their administrators to have recruiting efforts targeted to males (Burt et al., 1994).

These various data sets portray a family planning system that for the most part does not serve male clients, although condoms are made available to the female clients. Because various data suggest that men believe contraception is a joint responsibility, future efforts to involve men may well be successful. For example, in the 1988 National Survey of Adolescent Males (aged 15–19), 97 percent of the young men responding agreed that ''before a young man has sexual intercourse with someone, he should know or ask whether she is using contraception," and 95 percent agreed that "if a young man does not want to have a child, he should not have intercourse without contraception" (Sonenstein and Pleck, 1994).

Opposition to Abortion

The Supreme Court ruling in 1973 that declared abortion legal in all 50 states and the District of Columbia spawned a vigorous movement to restrict access to and the legality of abortion in the United States. Variously labeled the "anti-abortion" or "right-to-life" movement, this force has had a marked presence in local, state, and national political campaigns, including the last few presidential elections, in family planning service programs and funding, and in the process by which funds are appropriated for research and for reproductive health services generally. The movement exists despite the fact that a majority of Americans continue to support the availability of safe, legal abortion, albeit with a variety of restrictions (Blendon et al., 1993), as noted earlier in this chapter. Organized opposition to abortion has led to legislative restrictions in numerous states on access to abortion (National Abortion and Reproductive Rights Action League, 1994), along with efforts to maintain blockades and other barriers at facilities where abortions are performed. In addition, some of those who oppose abortion now extend their opposition to other issues as well, such as school-based sex education, and are increasingly active at the local level,

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

where they may seek to influence the composition of school boards and to control the content of curricula regarding human sexuality. The increasing stridency and polarization of public debate over abortion, sex education, and other related topics has created an atmosphere that endangers political and public financial support for sex education, family planning, and the provision of legal abortions.

The growing intensity even endangers the lives and resources of those providing these services, as the increasingly vehement rhetoric may be seen as a signal to action by those prone to violence. In particular, the movement has been associated with systematic and increasing harassment of abortion facilities and their personnel, including several murders. The National Abortion Federation (1993) reported that between 1977 and 1993, there were more than 6,000 incidents of clinic disruptions, 589 blockades against family planning and abortion clinics, and almost 1,500 acts of violence against abortion providers. Abortion facilities that are not based in hospitals are more likely to be harassed than those that are based in hospitals, as are facilities that perform relatively higher volumes of abortion. More than half of the providers who perform more than 400 abortions annually report that they have been picketed at least 20 times annually as well (Henshaw, 1991).

The relationship of abortion opposition to unintended pregnancy centers on three issues: first, because some facilities that provide abortions also dispense contraceptive services and supplies, any restriction on access to abortion facilities may also limit access to contraception; second, the number of unintended pregnancies resolved by abortion rather than childbearing may be affected; and three, the general climate of controversy created around the issue of abortion may spill over into other areas of reproductive services and education, confusing clients about what services are actually available and with what restrictions, affecting the morale and performance of those who work in the family planning field, and encouraging an atmosphere of high emotion on all issues of reproductive and sexual health, not just abortion.

With regard to the first issue, data show that only about 85 of the 4,000 contraceptive clinics that receive funding from the federal Title X program perform abortions (using funds other than Title X funds); and about half of these 85 are in hospitals (L. Kaeser, pers. com., 1994). Looked at from the opposite side, however, it is also apparent that many abortion facilities also are a main source of contraceptive services as well. Depending on how one defines a "nonhospital abortion facility," in 1989 somewhere between 83 and 94 percent of such facilities also provided contraceptive care to nonabortion patients. These facilities also offer many other services, including screening and treatment for STDs, general gynecologic care, and infertility services (Henshaw, 1991). To the extent that these facilities and their clients are harassed because of the facilities' abortion activities, access to contraceptive services is compromised, which in turn may contribute to the incidence of unintended pregnancy. Crossing

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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a picket line to obtain an abortion is undoubtedly stressful; crossing the same picket line for a contraceptive visit—or even worrying that obtaining contraception could require confronting protesters—might be enough to avoid making the trip altogether and cause a couple to rely instead on less effective, nonprescription methods of birth control.

With regard to the second issue—that the ratio between unintended pregnancies resolved by abortion rather than childbearing may be affected by opposition to abortion—there are some data to suggest a possible connection. Recently, the number of abortions performed in the United States has begun to decline; in 1992, 1.5 million abortions occurred versus 1.6 million in 1990 (Henshaw and Van Vort, 1994), and a decreasing proportion of all pregnancies, including unintended pregnancies, are now being resolved by abortion (Henshaw and Van Vort, 1994; Henshaw et al., 1991) (see also Chapter 2). It is possible that at least one reason for such trends is the discomfort and fear among both patients and providers caused by the harassment described above. Other factors that may help to explain the decreasing number of abortions include a changing age structure in the population, with more women in the older age groups among whom abortion is less common, and less punitive attitudes towards nonmarital childbearing (Henshaw and Van Vort, 1994).

An additional factor that is probably contributing to the decrease is the decline in the number of facilities that perform abortions. Between 1978 and 1992, for example, the number of counties that reported the presence of at least one abortion provider declined by more than 30 percent, such that by 1992 more than 80 percent of all counties in the United States and more than half of all metropolitan counties had no abortion provider at all. Similarly, it is estimated that over the last decade and more, the number of clinics, hospitals, and physician offices that perform abortions has declined by approximately 65 a year (Henshaw and Van Vort, 1994). Again, this may reflect fear among providers, some of whom are understandably reluctant to work at an clinic that provides abortion services. The decline in the number of abortion providers may also reflect the limited training in the procedure that many physicians now receive, particularly as compared to several years ago. Goldstein (1995:A11) recently reported that "in 1975, two years after Roe, all but 7 percent of U.S. medical schools offered training in abortion to obstetrics residents, and 26 percent required it. By 1992, one third were not given any training, even when residents requested it, and 12 percent included it as a requirement." Similarly, Westoff and colleagues (1993) report that most programs training family practice physicians as well as obstetrician-gynecologists do not require competency in this procedure. Although the Accreditation Council for Graduate Medical Education recently revised its requirements for obstetrics-gynecology residency programs to insist that training in abortion be provided (with a few narrowly defined exceptions for religious or moral objections), these new requirements will not

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

take effect until 1996, and their impact on abortion availability may not be apparent for several more years after that.

The third issue—that the general climate of controversy created around the issue of abortion may spill over into other areas of reproductive services and education—is less easily documented, although field reports suggest that this is the case. Some of the more vocal opposition to sex education provided in the schools, for example, is reported to be from anti-abortion groups (Haffner, 1994). Furthermore, Zero Population Growth (1993) reports that "the majority of anti-abortion organizations are also opposed to the use of and access to contraception." In part, this is probably due to the fact that some of these groups are loosely affiliated with, or closely tied philosophically to, the Catholic Church, which has taken a strong stand against all forms of contraception except periodic abstinence. The recent bombings of four contraceptive clinics that perform no abortions at all (located in Pennsylvania, Minnesota, Ohio, and Vermont) suggest that the high level of conflict that surrounds abortion may indeed place those who provide other related services at risk of violence and harassment (C. Glazer, pers. com., 1994).

It is also important to note that opposition to abortion, sometimes accompanied by opposition to organized family planning programs as well, has also affected a surprisingly wide variety of basic statistical and research functions related to unintended pregnancy. For example, some state and local systems to collect information on the number of abortions being performed (as well as on their possible complications) have been curtailed. That is, because some object to abortion, fewer abortion-related data are collected—a development that has affected the federal abortion surveillance system operated by the CDC, which relies on these state and local estimates in compiling its own aggregate statistics. Similarly, some systems to collect information on publicly supported family planning programs were shelved for years; research sponsored by such public agencies as the National Institutes of Health has been scrutinized and occasionally reshaped quite directly by abortion opponents; and efforts to increase public information and education about such lethal problems as HIV/AIDS have been stymied as well. The net result of such ideologically-driven developments has been to create a climate in which it has been increasingly difficult to take action to reduce unintended pregnancy, inasmuch as this particular problem can easily get entangled in the "culture wars" of recent years about abortion, contraception, and sexual behavior—wars that appear to be ongoing.

Conclusion

Many of the factors that may influence contraceptive use and therefore unintended pregnancy touch some of the most controversial and important issues facing contemporary U.S. society. The large number and great complexity of

Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
×

these forces—cultural values regarding sexuality, racism, violence against women, gender bias, the content of the media, and others as well—suggest that no single or simple remedy is likely to solve the unintended pregnancy problem. Research has not probed how some of the issues noted earlier in this report—contraceptive knowledge and access, as well as personal and interpersonal factors—are affected by the larger social phenomena outlined in this chapter. Nonetheless, it is reasonable to conclude that achieving major reductions in unintended pregnancy will require that socioeconomic and cultural issues be engaged.

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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Suggested Citation:"Socioeconomic and Cultural Influences on Contraceptive Use." Institute of Medicine. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/4903.
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Experts estimate that nearly 60 percent of all U.S. pregnancies--and 81 percent of pregnancies among adolescents--are unintended. Yet the topic of preventing these unintended pregnancies has long been treated gingerly because of personal sensitivities and public controversies, especially the angry debate over abortion. Additionally, child welfare advocates long have overlooked the connection between pregnancy planning and the improved well-being of families and communities that results when children are wanted.

Now, current issues--health care and welfare reform, and the new international focus on population--are drawing attention to the consequences of unintended pregnancy. In this climate The Best Intentions offers a timely exploration of family planning issues from a distinguished panel of experts.

This committee sheds much-needed light on the questions and controversies surrounding unintended pregnancy. The book offers specific recommendations to put the United States on par with other developed nations in terms of contraceptive attitudes and policies, and it considers the effectiveness of over 20 pregnancy prevention programs.

The Best Intentions explores problematic definitions--"unintended" versus "unwanted" versus "mistimed"--and presents data on pregnancy rates and trends. The book also summarizes the health and social consequences of unintended pregnancies, for both men and women, and for the children they bear.

Why does unintended pregnancy occur? In discussions of "reasons behind the rates," the book examines Americans' ambivalence about sexuality and the many other social, cultural, religious, and economic factors that affect our approach to contraception. The committee explores the complicated web of peer pressure, life aspirations, and notions of romance that shape an individual's decisions about sex, contraception, and pregnancy. And the book looks at such practical issues as the attitudes of doctors toward birth control and the place of contraception in both health insurance and "managed care."

The Best Intentions offers frank discussion, synthesis of data, and policy recommendations on one of today's most sensitive social topics. This book will be important to policymakers, health and social service personnel, foundation executives, opinion leaders, researchers, and concerned individuals. May

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