Missing the Boat on Pregnancy Prevention
Teenage pregnancy grabs the headlines, but most unintended and unwanted pregnancies occur among adults.
In the past year, new national efforts have been launched that are aimed at reducing the large numbers of unintended pregnancies among U.S. teenagers. Yet even if these efforts are dramatically successful, they will make only a dent in the problem of unintended pregnancy, because about three-fourths of the 3.1 million unintended pregnancies in the United States each year occur among adults. Indeed, more than half of the 4.5 million pregnancies among women 20 years of age or older are unintended.
The 60 percent unintended pregnancy rate in the United States has remained virtually unchanged since the early 1980s and is by far the highest in the industrialized world. Even if the United States were to achieve the 30 percent target set by the U.S. Public Health Service in its Healthy People 2000 initiative-which is unlikely without major new investments in broad-based pregnancy prevention programs-it would still have higher rates than Canada, the United Kingdom, and various northern European countries.
Unintended pregnancies place enormous burdens on individuals, families, and communities, burdens that Americans are largely unaware of except as they relate to teens. These burdens are unlikely to diminish, however, unless Americans begin to confront a deep cultural bias: the belief that unintended pregnancies among adults are common and inevitable. The attitude in cultures that have much lower rates of unintended pregnancies is that these are unfortunate and rare events that occur despite our best intentions. It is time to adopt and promote a new norm: All pregnancies should be intended-that is, they should be consciously and clearly desired at the time of conception. This is the main conclusion of a report by an Institute of Medicine (IOM) committee on which I served.
Unintended pregnancies are not just unwanted pregnancies. They also include mistimed pregnancies-conceptions that happen too soon-which can interrupt or postpone educational or vocational goals. Whereas 28 percent of all U.S. births are mistimed and 11 percent are unwanted at conception, the proportion of unwanted pregnancies among adults (among all unintended pregnancies ending in birth) is much higher than it is for teens, most of whom want to have children at some time because they are still at the beginning of their childbearing years. Put another way, fully 90 percent of the children born from unwanted conceptions have mothers older than 19, and 70 percent have married adult parents. Many children born after an unwanted conception are born into poverty. Among ever-married women living below the federal poverty line, more than one in five of their children were not wanted at the time they were conceived. However, unwanted conceptions know no economic barriers: One in 10 of all children born to married women are unwanted at conception.
From a societal perspective, unintended conceptions carry a high cost. About one-half of unintended pregnancies among women 15 to 34 years old are terminated by abortion. For older women, the proportion ending in abortion increases to almost 60 percent. This reflects the higher proportion of unwanted conceptions among the unintended pregnancies of older women. Married women terminate more than one-fourth of their unintended conceptions. When women are grouped by income, those on either extreme choose abortion less often than women living just above the federal poverty line, who resolve 58 percent of their unintended pregnancies with an abortion.
Although abortion has few, if any, long-term negative effects on a woman's physical or psychological well-being, the decision to terminate a pregnancy can pose difficult moral or ethical problems. The high U.S. abortion rate fosters political and social tensions that cast a pall over rational discussions about meeting the needs of couples for pregnancy prevention and family planning. President Clinton's goal of making abortion "safe but rare" will be achieved only when unintended pregnancies are rare among adults as well as teens.
Unintended pregnancies also contribute to high social welfare costs. More than one-third of public spending for Aid to Families with Dependent Children (AFDC), Medicaid, and food supplement programs goes to support children who were unintended at conception. Those costs could be significantly reduced if unwanted conceptions were prevented.
Many children born after an unintended conception face the additional burden of being reared by only one parent. Almost three-fourths of births to single women began as unintended conceptions, and more than one-half of the births to formerly married women are a result of unintended conceptions. Single parenthood creates social and economic pressures on parents and children, no matter what the parent's age or economic status at the time of the child's birth. A child is more likely to suffer developmental and school problems if he or she grows up in a single-parent household-regardless of whether the parents were married at the time of the child's birth. Children who were unwanted at conception also face an increased chance of failing to achieve their full potential because of neglect, abuse, or economic and social deprivation. The risks related to unwanted conceptions are additive, increasing the risks already associated with being born into poverty or to unmarried women.
Regardless of marital status, the mother in an unwanted pregnancy is less likely to receive adequate prenatal care and more likely to expose the fetus to smoking and alcohol. The frequent result, not surprisingly, is a baby with a low birth weight. The risk that such a child will die before a first birthday is also greater. It is estimated that the elimination of unwanted conceptions would result in a 7 percent reduction in the low-birthweight rate among African American infants and a 4 percent reduction among white infants, an improvement that would not only reduce overall risks but also narrow the persistent black/white gap in low-birthweight babies.
The societal, family, and personal costs of unintended pregnancies among adults are high and may be growing. Studies of trends in unwanted and mistimed pregnancies suggest that the steep increase observed between 1982 and 1988, especially for women living below the poverty line, has continued into the 1990s.
Sex education for adults
In our multicultural society, there is no single childbearing norm for all men and women of childbearing age. Adults generally agree that teen pregnancy is unhealthy for both the young parents and their children. However, norms regarding adult childbearing are not well studied or understood. Traditionalists accept the need for sex education for teens, so long as it teaches only abstinence. Virtually no sex education is targeted at adults.
For teens, the IOM committee found that abstinence-only sex education fails to delay the onset of sexual intercourse and does not increase the use of contraceptives once intercourse begins. On the other hand, sex education that teaches abstinence in the context of maturation and includes information and access to contraception for teens who do become sexually active has been shown to postpone the initiation of sexual experimentation and to increase the likelihood that teens will use contraception the first time. Unfortunately, state laws and regulations often prohibit contraceptive counseling and distribution where it is most needed: in schools. There are no studies of the impact of sex education for teens on adult reproductive behavior, nor are there federal programs to provide sex education directly to adults. As a result, most of those in need of sex education do not receive it.
Unintended pregnancy touches on many deeply held beliefs and social taboos about sexuality, privacy, and parenting. The media reflects the constant challenge to these beliefs and taboos. Although thousands of blatantly sexual scenes play out on television and movie screens each year, ignoring our traditional cultural norms of modesty and marital fidelity, contraceptive ads are thought to be taboo. Few programs include references to the possible consequences of unprotected sex or sex without commitment. The message seems to be that it's okay to be swept away in a moment of passion, but openly discussing the consequences of unplanned sex is unnecessary or improper. Not surprisingly, many sexually active men and women are ignorant about how to choose among contraceptive methods, the safety of contraceptives, and the noncontraceptive benefits of certain contraceptives; for example, oral contraceptives provide some protection against ovarian cancer, endometrial cancer, and pelvic inflammatory disease.
Title X, the federal family planning program, was initiated in the early 1970s to give poor women the same access to effective family planning services as enjoyed by wealthier women. The benefits of family planning were then widely accepted. Now, the need for family planning is discussed only reluctantly, if at all. This profound change in the level of public discussion and understanding is directly related to the politics of abortion. Both abortion proponents and opponents have linked family planning and abortion, leaving family planning services budgets vulnerable to cuts. (Funding for the federal family planning program was cut by half during the 1980s, although much of the loss was offset by increased state and local spending.)
Today, family planning services are often hard to obtain, with long waiting periods. Private insurers often do not cover the cost of contraceptives, and many poor and near-poor women do not qualify for Medicaid-funded family planning services. In addition, obtaining effective contraceptives is confusing and often expensive in today's health care system. Reducing unintended pregnancy and abortions will require improved services, improved contraceptives, and better use of currently available contraceptives.
National campaign needed
Achieving the lofty goal that every pregnancy be intended will require the adoption of new behaviors. A broad-based approach, similar to the efforts used to discourage smoking or to encourage seatbelt use, will be needed. But because human sexual behavior is both private and morally charged, efforts to promote a new childbearing norm will clearly be more difficult than changing smoking behavior. A national campaign to reduce unintended pregancies should focus on five core goals:
Improve knowledge about sex, contraception, and reproductive health. National surveys reveal that many adults lack even the most basic information on human sexuality and contraception. Many people mistakenly believe that childbearing is less risky medically than using oral contraceptives. Emergency contraception [the use of oral contraceptives or other hormones up to 72 hours after unprotected intercourse or the insertion of an intrauterine device (IUD) up to seven days afterward] is only beginning to be recognized as an important pregnancy prevention methodology, despite its effectiveness and availability. Most men are not aware of the need to use condoms to prevent pregnancy when their partners are using nonpermanent contraception. Although some couples in the United States do practice dual contraception (the use of both condoms and effective female methods), this practice is neither widespread nor explicitly encouraged through health care providers and health-promotion literature.
To improve adult awareness, efforts must be made to reach out to the electronic and print media, which often sensationalize the few risks involved with contraceptive methods. Media representatives need to be convinced about the need to discuss accurate information on the risks and benefits, including the noncontraceptive benefits, of contraception. The story lines of television shows and movies need to be broadened to include rational decisionmaking regarding contraception in the context of lovemaking. Public service announcements should be more plentiful, and contraceptive advertisements should be permitted and widely disseminated.
Increase access to contraception. The 6 million women who use no contraception despite their stated desire to avoid pregnancy account for half of all unintended pregnancies. These women may be "between methods" because of delays in obtaining family planning services caused by lack of funding for family planning clinics. They may be on a waiting list to obtain a tubal ligation. Or they may not know of an effective method that meets their particular needs. U.S. women do not have access to every form of contraception. Many women do not have even have access to legal methods such as IUDs, either because their health care providers are not trained in those methods or the provider does not include them in its list of prescribed services.
Providing couples with effective contraceptives (such as the copper-T IUD, vasectomy, contraceptive implants, or injectable contraceptives) can be highly cost-effective for health care providers. Conscientious use of an effective contraceptive over a five-year period, according to one study, will prevent slightly more than four unintended pregnancies, with a cost saving of $13,000 to $14,000, depending on the contraceptive method chosen. At present, however, much of the cost of contraceptives is borne by the consumer, not the health care provider. It would make great sense for providers to offer comprehensive coverage of all types of contraceptive services. Employers should push to include comprehensive contraceptive coverage, with no co-payer costs, in the policies that they buy.
In the public sector, barriers to Medicaid coverage for low-income people must be eliminated. Currently, Medicaid covers family planning services only for women in the AFDC program and for postpartum women for 60 days after delivery. Men are not covered for vasectomies or condoms. Medicaid should cover family planning services for all sexually active women and men with incomes below 185 percent of the federal poverty level. In addition, funding for the Title X Family Planning Program should be expanded to provide for walk-in service and to reduce waiting times. Emergency contraceptive services need to be made widely available and free of charge.
In countries with the lowest unintended pregnancy rates, such as the Netherlands, men routinely use condoms in all sexual encounters, in recognition of their culturally accepted joint role in protecting the couple from unintended conceptions. Combining condom use with oral contraceptives or other effective female methods could reduce accidental pregnancies among contraceptive users by as much as 80 percent. However, only about 10 percent of men report that their health care provider even mentions contraceptives or prevention of sexually transmitted diseases during their health care visit. Indeed, there are many missed opportunities within primary care settings for promoting the reproductive health of both men and women. Pediatricians, family practitioners, internists, urologists, cardiologists, and other physicians must be trained in offering family planning advice and referrals within the context of their practices.
In short, no one should fail to obtain effective contraception because of ignorance, cost, time required to obtain service, availability of an appropriate method, or convenience in obtaining the method. Eliminating these barriers would go far in reducing unintended pregnancies.
Provide ample guidance to couples to ensure that they use contraception effectively, including addressing feelings, attitudes, and motivation. In about half of all unintended pregnancies, conception occurs despite the use of some sort of contraception. It takes strong, continuous motivation to use contraception during the long period that a fertile woman does not wish to be pregnant. Critical to this motivation is the perception that the negatives associated with contraception are far outweighed by the negatives of unintended pregnancy. To sustain such motivation, health care providers and contraceptive counselors need sufficient training and time with clients to provide sensitive and personalized counseling about the skills and commitment needed to make contraception work. Health care providers must have a thorough understanding of the potential side effects of contraceptives so that they can steer couples to contraceptive methods with the least troublesome side effects. Despite the emphasis on minimizing time spent with clients in today's managed care settings, this time-consuming counseling is essential.
Experiments with this broad approach are under way in some managed care settings, such as Kaiser Permanente's northern California locations. Included in Kaiser's extensive Prevention and Health Promotion manual are guidelines for counseling to prevent unintended pregnancy, with separate guidelines for adolescents and adults. The practice steps for primary care providers include obtaining a sexual history, discussing contraceptives and their proper use, reinforcing methods to prevent sexually transmitted disease, and (for women) providing preconception counseling for nutrition, alcohol, and smoking.
Health care providers and counselors must also understand the role that the environment of poverty and hopelessness may play in eroding motivation to prevent unintended pregnancy. Low-income couples must have access to positive alternatives to unintended childbearing, such as jobs and opportunities for personal growth and education.
Expand and scrupulously evaluate local pregnancy prevention programs. Funding for research and demonstration projects must be adequate to assure full evaluation of their effectiveness. To date, only 23 programs have been sufficiently evaluated, and none of these has targeted adults. Building on the very limited database of well-evaluated programs, new efforts should focus on research and demonstration projects that encourage couples not currently using contraceptives to do so. Programs must be multifaceted, providing supplies, information, education, case management and follow-up, attention to motivational issues, and skills in negotiation and use. Men need to be involved more effectively in decisions and actions to prevent pregnancy. Communities, too, need to be more effectively involved, perhaps by working to change attitudes toward unintended pregnancy.
Stimulate research. As many experts have noted, new contraceptive methods are urgently needed for men and women. All currently available methods meet some, but not all, of a couple's needs, and no method provides complete protection. Until better methods are developed, more research should focus on how to get men and women to practice contraception simultaneously. For example, behavioral research is needed to understand what motivates a mutually monogamous couple to use or not use a condom and a safe female method at the same time. Health service researchers need to study how to more effectively target family planning messages and services at men. Social scientists should address cultural issues involving unintended pregnancy and how best to intervene to promote intentional conceptions. Efforts such as those of the National Association of County and City Health Officials to reduce unintended pregnancy among adults should be encouraged. The association has convened a working group of individuals representing disparate views on family planning and abortion to try to encourage dialogue and collaboration. This is a small step, but it deserves additional attention and resources.
Americans need to face up to the burden they are placing on children by ignoring the problem of unintended pregnancy among adults. The focus on teen pregnancy, though very important, is woefully insufficient. Public education and discussion of the problem is a necessary first step. Ultimately, however, the solution will require a cultural change-an understanding of and commitment to the belief that every pregnancy should be consciously and clearly desired at the time of conception.
J. C. Abma et al., "Fertility, Family Planning, and Women's Health: New Data from the 1995 National Survey of Family Growth," Vital Health Statistics, series 23, No. 19.
P. F. Harrison and A. Rosenfield, Contraceptive Research and Development: Looking to the Future. Washington, D.C.: National Academy Press, 1996.
R. A. Hatcher et al., Contraceptive Technology (17th revised edition). New York: Irvington Publishers, 1997 (forthcoming).
R. A. Hatcher et al. Emergency Contraception: The Nation's Best Kept Secret. Atlanta, Ga.: Bridging the Gap Communications, 1995.
J. Trussell et al., "The Economic Value of Contraception: A Comparison of 15 Methods," American Journal of Public Health Vol. 1985, No. 85, pp. 494-503.
Carol J. Rowland Hogue is the Terry Professor of Maternal and Child Health and professor of epidemiology at Emory University's Rollins School of Public Health. She was a member of the Institute of Medicine's Committee on Unintended Pregnancy, which produced the report The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families (Washington, D.C.: National Academy Press, 1995).