Lead Agency:		Office of Population Affairs

[Note: The National Library of Medicine has provided PubMed links to available references that appear at the end of this focus area document.]

Contents

GoalPage 9-3

Overview. Page 9-3

Issues and Trends. Page 9-3

Disparities. Page 9-6

Opportunities. Page 9-7

Interim Progress Toward Year 2000 Objectives. Page 9-8

Healthy People 2010—Summary of Objectives. Page 9-10

Healthy People 2010 Objectives. Page 9-11

Related Objectives From Other Focus Areas. Page 9-30

Terminology. Page 9-31

References. Page 9-32

Improve pregnancy planning and spacing and prevent unnintended pregnancy.

In an era when technology should enable couples to have considerable control over their fertility, half of all pregnancies in the United States are unintended.[1] Although between 1987 and 1994 the proportion of pregnancies that were unintended declined in the United States from 57 to 49 percent,[2] other industrialized nations report fewer unintended pregnancies,[3] suggesting that the number of unintended pregnancies can be reduced further. Family planning remains a keystone in attaining a national goal aimed at achieving planned, wanted pregnancies and preventing unintended pregnancies. Family planning services provide opportunities for individuals to receive medical advice and assistance in controlling if and when they get pregnant and for health providers to offer health education and related medical care.

The family planning objectives for Healthy People 2010 echo the recommendations contained in the 1995 Institute of Medicine report The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families.[4] The foremost recommendation of the report calls for the Nation to adopt a social norm in which all pregnancies are intended—that is, clearly and consciously desired at the time of conception. Emphasizing personal choice and intent, this norm speaks to planning for pregnancy, as well as to avoiding unintended pregnancy.

Unintended pregnancy rates in the United States show a decline, probably as a result of higher contraceptive use and use of more effective contraceptive methods.2 Despite this improvement, unintended pregnancy remains a common problem, and further progress is needed.

Issues and Trends

One important determinant of pregnancy and birth rates is contraceptive use. The proportion of all females aged 15 to 44 years who currently are practicing contraception (including females who have been sterilized for contraceptive reasons and husbands or partners who have had vasectomies) rose from about 56 percent in 1982 to 60 percent in 1988 and 64 percent in 1995.[5] However, 5.2 percent of all females aged 15 to 44 years had intercourse in the past 3 months and did not use contraceptives.5

No one method of contraception is likely to be consistently and continuously suitable for each woman, man, or couple. Total abstinence is the only fool-proof method of contraception. Sterilization, the most common method of contraception in the United States, has near-perfect effectiveness and differs from other methods because it is usually permanent.5

Used by an estimated 10 million females, combination oral contraceptives are the most popular method of reversible contraception in the United States. Other hormonal contraceptives, such as injectables and implants, and intrauterine devices (IUDs) have the appeal of providing effective contraception without the need for daily compliance. For barrier methods, such as the condom and diaphragm, the average effectiveness is more variable. Used correctly and consistently, condoms can prevent both pregnancy and disease. Other barrier methods include the diaphragm, cervical cap, and female condom, which may reduce the risk but do not prevent sexually transmitted diseases (STDs) that primarily affect the cervix. Spermicides used alone (foams, creams, and jellies), coitus interruptus (withdrawal), and periodic abstinence (calendar rhythm) are other options; however, their effectiveness in actual use is lower than that for other methods.

Contraceptive method choices are far from ideal. Even with all financial and knowledge barriers removed, effective and consistent contraceptive use is difficult. Contraceptive research and development efforts must be expanded to bring new methods to the market, methods that combine high contraceptive efficacy and ease of use with protection against STDs and human immunodeficiency virus (HIV). Increased attention also must be given to bringing new methods to the United States, including male methods of contraception, spermicide, and microbicide alternatives. Improving the range of contraceptive choices increases the likelihood that individuals and couples will be able to find a contraceptive method that suits them. Greater choice enhances individuals’ control over their fertility and reduces the risk of unintended pregnancy.

Reducing unintended pregnancies is possible and necessary. Unintended pregnancy in the United States is serious and costly and occurs frequently. Socially, the costs can be measured in unintended births, reduced educational attainment and employment opportunity, greater welfare dependency, and increased potential for child abuse and neglect. Economically, health care costs are increased. An unintended pregnancy, once it occurs, is expensive no matter what the outcome. Medically, unintended pregnancies are serious in terms of the lost opportunity to prepare for an optimal pregnancy, the increased likelihood of infant and maternal illness, and the likelihood of abortion.4 The consequences of unintended pregnancy are not confined to those occurring in teenagers or unmarried couples. In fact, unintended pregnancy can carry serious consequences at all ages and life stages.4

With an unintended pregnancy, the mother is less likely to seek prenatal care in the first trimester and more likely not to obtain prenatal care at all.[6], [7] She is less likely to breastfeed[8] and more likely to expose the fetus to harmful substances, such as tobacco or alcohol.4 The child of such a pregnancy is at greater risk of low birth weight, dying in its first year, being abused, and not receiving sufficient resources for healthy development.[9] A disproportionate share of the women bearing children whose conception was unintended are unmarried or at either end of the reproductive age span—factors that, in themselves, carry increased medical and social burdens for children and their parents. Pregnancy begun without some degree of planning often prevents individual women and men from participating in preconception risk identification and management.

For teenagers, the problems associated with unintended pregnancy are compounded, and the consequences are well documented. Teenaged mothers are less likely to get or stay married, less likely to complete high school or college, and more likely to require public assistance and to live in poverty than their peers who are not mothers. Infants born to teenaged mothers, especially mothers under age 15 years, are more likely to suffer from low birth weight, neonatal death, and sudden infant death syndrome. The infants may be at greater risk of child abuse, neglect, and behavioral and educational problems at later stages.[10] Nearly 1 million teenage pregnancies occur each year in the United States.[11] Clearly, the solution to the problem needs to be found.

Unintended pregnancy is expensive, and contraceptives save health care resources by preventing unintended pregnancy.[12] The pregnancy care cost for one woman who does not intend to be pregnant, yet is sexually active and uses no contraception, is estimated at about $3,200 annually in a managed care setting.12, [13] Estimates of the overall cost to U.S. taxpayers for teenage childbearing range between $7 billion and $15 billion a year, mainly attributed to higher public assistance costs, foregone tax revenues resulting from changes in productivity of the teen parents, increased child welfare, and higher criminal justice costs.[14] Unintended births to teenagers, which account for about 40 percent of teenaged pregnancies, cost more than $1.3 billion in direct health expenditures each year.[15]

Induced abortion is another consequence of unintended pregnancy. Although the numbers of abortions in this country have been declining over the past 15 years,[16] approximately one abortion occurs for every three live births annually in the United States, a ratio two to four times higher than in many other Western democracies. Just as unintended pregnancy occurs across the spectrum of age and socioeconomic status, women of all reproductive ages, married or unmarried, and in all income categories obtain abortions.

Abortion results when women have unintended pregnancies, and adequate access to family planning services reduces the number of unintended pregnancies. Each year, publicly subsidized family planning services prevent an estimated 1.3 million unintended pregnancies.[17] For every $1 spent on publicly funded contraceptive services, $3 is saved in Medicaid bills for pregnancy-related health care and medical care for newborns.17

Disparities

Unintended pregnancies occur among females of all socioeconomic levels and all marital status and age groups, but females under age 20 years and poor and African American women are especially likely to become pregnant unintentionally.4 More than 4 in 10 pregnancies to white and Hispanic females are unintended; 7 in 10 pregnancies to African American females are unintended. Unintended pregnancies during contraceptive use are most common among African American and Hispanic females. Poverty is strongly related to greater difficulty in using reversible contraceptive methods successfully, with these females also the least likely to have the resources necessary to access family planning services and the most likely to be affected negatively by an unintended pregnancy. For this reason, publicly subsidized family planning services are important. Yet, half of all females who are at risk for an unintended pregnancy and need publicly subsidized family planning services are not getting them.[18] Clearly, while these programs have contributed substantially to preventing unintended pregnancy, the need for services continues to outstrip resources available.

Difficulty in obtaining and paying for care is, of course, exacerbated for poor and low-income people. Several Federal programs support family planning services, with most targeting poor or low-income females. The Medicaid program is the largest, but reimbursement for family planning services is typically not available to adolescents, women without children, women who are married, and working poor women whose income may just exceed the eligibility level.

An estimated 6.6 million females receive services from subsidized family planning providers annually, slightly less than one-half of those considered to be in need of subsidized family planning services (those at risk of unintended pregnancy and with a family income less than 250 percent of the poverty level).[19] Family planning programs consisting of some 3,000 agencies with over 7,000 clinic locations provide nearly 40 percent of family planning services in the United States. Health departments represent nearly half of these locations, along with hospitals, community health centers, and other public and nonprofit organizations. Nearly two-thirds of all females served (4.2 million) obtained care at 1 of 4,200 clinics receiving funds from the Federal Title X Family Planning Program.19

Opportunities

A 1995 survey of the Nation’s family planning agencies estimated that almost 70 percent of agencies have at least one special program of outreach education or service to meet the needs of teenagers. Fewer have special programs for hard-to-serve populations, such as homeless persons, persons with disabilities, or substance abusers.[20] Furthermore, whether those agencies target their services or simply provide care to those who happened to seek it is not known.[21] The need for family planning services among all these groups is undeniably great. In the case of substance abuse, the link between illegal drug use and infection with HIV has meant more Federal and State funding for programs designed to reach these groups. Thus, substance abusers may be more likely to be targeted by family planning agencies than other hard-to-reach populations. Some programs focus specifically on HIV prevention, whereas others offer comprehensive family planning services and related education and counseling.21

Language and cultural differences are significant barriers to serving non-English-speaking population groups. Providers report that they often have difficulty finding staff with appropriate language skills who also have adequate family planning skills and experience. Furthermore, simply speaking the language of the client is not sufficient; the provider also must be able to relate on a cultural level.21 Persons of various ethnic backgrounds often are uncomfortable talking to strangers about intimate topics, such as sex and birth control, let alone undergoing a pelvic or breast exam. Some racial and ethnic groups tend to visit a doctor only when they are sick and not to seek preventive services, including family planning. Reaching such populations can be difficult.

Providing outreach, education, and clinical services to hard-to-reach populations is expensive. Frequently, these groups have more health problems than less disadvantaged family planning clients, and these health problems are not necessarily confined to family planning. One study estimated that the cost of providing services to homeless women is twice that of other women, with homeless women at such high risk of gynecological problems that they must undergo a complete exam and diagnostic workup at every visit.21 Disabled individuals often require extra staff, equipment, and time (especially if they are clients with developmental disabilities) to ensure contraceptive compliance and to deal with side-effect issues.21 The extra time, effort, and expense required to reach hard-to-serve groups undoubtedly discourage some family planning agencies from implementing programs for these populations.20 Clearly, there is a need to expand services to hard-to-reach populations and to find effective strategies to overcome barriers to services experienced by individuals in these populations.

Finally, public education and information about family planning need to be expanded. Public education efforts and the media could help persons to understand better the benefits of sexual abstinence. Numerous studies and polls indicate a disturbing degree of misinformation about contraceptive methods. The modest health risks of oral contraceptives frequently are exaggerated, whereas the more considerable benefits are underestimated. Knowledge about emergency contraception is not widespread, and the relative effectiveness of various contraceptive methods often is not well understood. Moreover, the risk of unintended pregnancy in the absence of contraceptive use is underestimated, and many population groups lack accurate information on STDs and reproductive health in general.[22] The media—print, broadcast, and video—must be encouraged to help in the task of conveying accurate and balanced information on contraception, highlighting the benefits as well as the risks of contraceptives.

Access to quality contraceptive services continues to be an important factor in promoting healthy pregnancies and preventing unintended pregnancies. Although people in the United States view contraception as basic to their lives and their health care, health insurance plans traditionally have not covered family planning services. Three-fourths of U.S. women of childbearing age rely on private insurance; the extent to which they are covered for contraception can differ dramatically depending on the type of insurance.[23] Traditional plans provide the least comprehensive coverage for family planning services, while health maintenance organizations (HMOs) and newer managed care plans provide more comprehensive contraceptive coverage. Increased access through insurance coverage for family planning is important because in the absence of comprehensive coverage, many women may opt for whatever method may be covered by their health plan rather than the method most appropriate for their individual needs and circumstances. Other women may opt not to use contraception if it is not covered under their insurance plan.

Of the 12 family planning Healthy People 2000 objectives, progress has been made for 9 objectives. Substantial decreases have occurred in unintended pregnancy. The use of contraceptives among females aged 15 to 44 years at risk for unintended pregnancy has increased. The pregnancy rate for females using a contraceptive method has declined. Increases in adolescents’ abstinence from sexual intercourse have occurred, as well as in their use of contraceptives. Although short of the year 2000 targets, decreases in adolescent pregnancy have been reported. Data are not available to update objectives on family planning counseling and age-appropriate preconception care counseling.

Note: Unless otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998–99.

 

Family Planning

Goal: Improve pregnancy planning and spacing and prevent unintended pregnancy.

Number	Objective Short Title
9-1	Intended pregnancy
9-2	Birth spacing
9-3	Contraceptive use
9-4	Contraceptive failure
9-5	Emergency contraception
9-6	Male involvement in pregnancy prevention
9-7	Adolescent pregnancy
9-8	Abstinence before age 15 years
9-9	Abstinence among adolescents aged 15 to 17 years
9-10	Pregnancy prevention and sexually transmitted disease (STD) protection
9-11	Pregnancy prevention education
9-12	Problems in becoming pregnant and maintaining a pregnancy
9-13	Insurance coverage for contraceptive supplies and services

 

9-1.		Increase the proportion of pregnancies that are intended.

Target: 70 percent.

Baseline: 51 percent of all pregnancies among females aged 15 to 44 years were intended in 1995.

Target setting method: Better than the best.

Data sources: National Survey of Family Growth (NSFG), CDC, NCHS; National Vital Statistics System (NVSS), CDC, NCHS; Abortion Provider Survey, The Alan Guttmacher Institute; Abortion Surveillance Data, CDC, NCCDPHP.

Pregnancies Among Females Aged 15 to 44 Years, 1995	Intended Pregnancy
	Percent
TOTAL	51
Race and ethnicity
American Indian or Alaska Native	DSU
Asian or Pacific Islander	DSU
Asian	DSU
Native Hawaiian and other Pacific Islander	DSU
Black or African American	28
White	57
Hispanic or Latino	51
Not Hispanic or Latino	51
Black or African American	DNA
White	DNA
Family income level
Poor	39
Near poor	47
Middle/high income	59
Select populations
Age groups
15 to 19 years	22
20 to 24 years	42
25 to 29 years	60
30 to 34 years	67
35 to 39 years	59
40 to 44 years	49
Marital status
Currently married	69
Formerly married	38
Never married	22