FAMILY PLANNING

The ability of couples to plan the size of their family and the timing of births has important sociological implications for both individual families and society as a whole. Women's roles and labor-force participation, the socialization of children, social and economic development, and ultimately the ability of the earth to sustain human life are all affected in one way or another by the ability of couples to practice family planning and the success with which they do so. In the United States, women expect to complete their childbearing with an average of 2.2 children per woman (Abma et al. 1997), and, on average, women have 2.0 births over their lifetime (Ventura et al.). Throughout the world, the average number of children desired varies from about two in most industrialized nations to between six and eight in some African nations (Alan Guttmacher Institute 1995). In order to limit lifetime births to the number desired, couples must abstain from intercourse, have high levels of contraceptive use, or resort to abortion. Indeed, sexually active women would average eighteen births over their lifetime if they used no contraception and no induced abortion (Harlap et al. 1991). This article summarizes information regarding sexual activity; the risk and occurrence of unplanned pregnancy; contraceptive use and failure; and the provision of family planning–related information, education, and services in the United States. For comparison, worldwide variation in the planning status of pregnancies and births and the use and availability of contraception are also presented.

EXPOSURE TO THE RISK OF PREGNANCY

Most Americans begin to have intercourse during their late adolescence and continue to be sexually active throughout their reproductive lives. In 1995, 55 percent of all men aged 15–19 in the United States had had intercourse (Sonenstein et al. 1998). Similarly, about half of all women aged 15–19 report ever having had sex (Table 1). These data, collected in 1995, indicate a leveling off in the trend toward earlier ages of sexual initiation. Whereas the percentage of adolescents who reported being sexually experienced rose steadily throughout most of the 1980s, the percentage of adolescent females who had ever had sex did not change significantly between 1988 and 1995 and the percentage of adolescent males who were sexually experienced actually fell during that period (Singh and Darroch 1999).

Once sexually active, most women become at risk for an unintended pregnancy. Table 1 shows information on the percentage of all U.S. women aged 15–44 who are at risk for becoming pregnant by age and union-status groups (currently married, cohabiting, formerly married or never married). The proportion who are not at risk of an unintended pregnancy because they have never had intercourse decreases quickly from 50 percent of teenagers 15–19 to only 1 percent of all women aged 35–44. Five to seven percent of women in all age groups have had intercourse but are not currently in a sexual relationship (i.e., they have not had sex within the last three months). Some 5 percent of women are infertile, or noncontraceptively sterile, because of illness, surgery (that was not for contraceptive purposes), menopause, or some other reason. The proportion that is infertile increases steadily with age, from 1 to 2 percent of women under 30 to about 13 percent of those aged 40–44. Some women, especially those in their twenties and early thirties, are not at risk of an unintended pregnancy because they are already pregnant, postpartum, or seeking pregnancy. Eleven to fifteen percent of women aged 20–34 are in this category.

Women who are at risk for an unintended pregnancy account for more than two-thirds of all women ages 15–44 at any point in time. Women at risk are those who are currently in a sexual relationship, are fertile, and wish to avoid becoming pregnant. The proportion of women at risk of unintended pregnancy increases from less than 40 percent of teenagers to about three-quarters of all women ages 25–44. Women who are currently married or cohabiting are most likely to be at risk for unintended pregnancy—81 to 83 percent of them are at risk, compared with 72 percent of formerly married women and 49 percent of nevermarried women. The most common reason some married or cohabiting women are not at risk of unintended pregnancy is that they are pregnant, postpartum, or trying to become pregnant. Among women who have never been married, never having had intercourse or no recent intercourse are the most common reasons.

OCCURRENCE OF UNINTENDED PREGNANCY

Nearly one-half of all pregnancies (49 percent) in the United States are unintended (Henshaw 1998), that is, they occur to women who want to have a baby later but not now (generally called "mistimed") or to women who did not want to have any (more) children at all (called "unwanted") (Table 2). The proportion of pregnancies that are unintended is highest among adolescents—78 percent—and varies considerably by age. The percentage of pregnancies that are unintended is lowest among women aged 30–34 (33 percent) and rises again among older women to 51 percent among women aged 40 and older. Unintended pregnancies are also relatively more likely to occur among never-married women (78 percent), black women (72 percent), and low-income women (61 percent for women under 100 percent of the federal poverty level).

The percentage of pregnancies that are unintended has declined in recent years—from 57 percent in 1987 to 49 percent in 1994 (see Table 2). These declines have occurred across all age categories but have been more significant among older women. These declines have also been more significant among low-income women. In 1987, 75 percent of all pregnancies to women with family incomes under 100 percent of the poverty level were unintended. This dropped to 61 percent in 1994. In comparison, the percentage of unintended pregnancies to women with incomes 200 percent or more of the federal poverty level fell from 45 percent in 1987 to 41 percent in 1994.

Among all unintended pregnancies, more than half (54 percent) end in an abortion while 46 percent result in an unintended birth. This relationship differs for adolescents, who, in recent years, have been more likely to resolve unintended pregnancies with a birth. More than one-half of all unintended pregnancies to adolescents result in an unintended birth (55 percent), while 45 percent are resolved with an abortion. These percentages represent a significant change in the resolution of unintended pregnancies among adolescents. Throughout the 1980s, adolescents who were pregnant unintentionally were more likely to obtain an abortion (55–53 percent) than to carry the pregnancy to term.

Nearly half (48 percent) of all women aged 15–44 have had at least one unintended pregnancy at some time in their lives; 28 percent have had one or more unplanned births, 30 percent have had one or more abortions, and 11 percent have had both. Given current rates of pregnancy and abortion, by the time they are 45 years old, the typical woman in the United States will have experienced 1.42 unintended pregnancies and 43 percent will have had an abortion.

Women who are using no contraceptive method account for about 8 percent of all women at risk of unintended pregnancy, but, because they are more likely to become pregnant than are those using a method, they account for nearly one-half of all unplanned pregnancies, an estimated 47 percent. Significant reductions in unintended pregnancy and abortion could occur with increased contraceptive use, with more effective use of existing methods, and with the development and marketing of additional methods.

CONTRACEPTIVE USE

Women and men in the United States rely on a variety of contraceptive methods to plan the timing and number of children they bear and to avoid unintended pregnancies. Surgical contraceptive sterilization is available to both men and women. Oral contraceptives, Depo Provera injectibles, Norplant implants, the IUD, and female barrier methods such as the diaphragm and the cervical cap are available from physicians and clinic providers. Other methods—condoms and spermicidal foam, cream, jelly, and film—can be purchased over the counter in pharmacies or other stores. Instruction in periodic abstinence is available from physicians and other family planning providers as well as through classes where only that method is taught.

More than nine in ten women aged 15–44 in 1995 who were at risk of unintended pregnancy

were using a contraceptive method, as shown in Table 3. Thirty-six percent relied on contraceptive sterilization of themselves or their partner, 52 percent used reversible medical methods, 5 percent used nonmedical methods such as withdrawal and periodic abstinence, and 7.5 percent were currently using no contraceptive, even though they were at risk of unintended pregnancy.

Patterns of contraceptive use differ by age. Younger women at risk of unintended pregnancy are more likely than older women to use no method of contraception. Nearly one in five teenage women at risk use no method, compared to 6 to 7 percent of women at risk aged 25 and older. The proportion using reversible medical methods declines steeply with age—from more than four out of five women aged 20–24 to less than one-quarter of those ages 40–44. Oral contraceptives are the most commonly used method among women under 30, used by 35 to 48 percent of these women. Condoms are second in popularity among this age group, used by 23 to 30 percent of women. Although fewer than 3 percent of women at risk use Depo Provera injectible contraceptives, this method has grown in popularity since its introduction into the United States, particularly among young women. Eight percent of teenagers at risk used this method. As women become older and complete their families, male and female contraceptive sterilization become increasingly common, rising steeply from 5 percent of women at risk aged 20–24 to one in five women in their late twenties and to two out of three women aged 40–44. Among women in their twenties, female sterilization is about four times more common than vasectomy. The margin narrows among older women to between two and two and a half times more common.

The proportion of women at risk of unintended pregnancy who use no contraceptive method is highest among never-married women, 14 percent as compared to 5 percent of those who are currently married or cohabiting and 8 percent of formerly married women. Sterilization is the most frequently used method among women who are currently married (46 percent) as well as formerly married women (50 percent). The pill is the most commonly used method among never-married women (38 percent) and cohabiting women (34 percent). Condoms are most likely to be used by never-married women (28 percent).

Although poor women and minority women at risk of unintended pregnancy have, in the past, been more likely than higher-income and nonHispanic white women to be using no contraceptive method, these differences have lessened. Compared to the 1980s, in 1995 there were no significant race/ethnicity or poverty differences in the percentages of women at risk of unintended pregnancy who used no method of contraception. However, there is some variation in the types of methods used among these subgroups. Low-income women are less likely to rely on reversible methods and more likely to rely on sterilization than higher income women. Forty percent of women at risk of unintended pregnancy who are under

150 percent of the poverty level use sterilization compared to 32 percent of women at 300 percent of the poverty level and above. Poor women relying on sterilization are much more likely than higher-income women to have been sterilized themselves rather than have a partner who has had a vasectomy. Female sterilization accounts for 92 percent of all contraceptive sterilization among poor women, compared with 58 percent among those with higher incomes.

CONTRACEPTIVE EFFECTIVENESS

Pregnancies occur to couples using contraceptive methods for two reasons—because of the inadequacy of the method itself or because it was not used correctly or consistently. Estimates have been made (either theoretically or empirically during clinical trials) regarding the efficacy of each contraceptive method given perfect use (Trussell 1998). In addition, estimates are made that measure the typical use effectiveness of each method, which relates to the experience of an actual group of users. The most recent estimates of typical use contraceptive effectiveness by method have been made using the 1995 National Survey of Family Growth, corrected for abortion underreporting and standardized for variation in the proportions of women from different subgroups using certain methods (Fu et al. 1999). Failure rates differ by method, with some methods consistently showing higher effectiveness than other methods. Rates also differ by sociodemographic subgroup within study populations.

Table 4 provides estimates of method-specific failure rates given both perfect use and typical use for the most commonly used reversible contraceptive methods. For each contraceptive method, the typical failure rates observed among women are substantially higher than the estimated rates given perfect use, and the rates differ widely among marital status, age, and poverty of women subgroups. The lowest failure rates are achieved with long-acting hormonal contraceptives that require little user compliance. Among methods that women must use daily or per coital episode, oral contraceptives are most effective, while spermicides, withdrawal, and periodic abstinence have the highest failure rates. In general, women who are young,

unmarried or cohabiting, and poor have higher failure rates. The differences in failure rates between methods and between subgroups of women are much greater than what any difference in method effectiveness or in the biology of women would cause and are assumed primarily to reflect differences in the correctness and consistency of method use (although reporting errors may also play a role).

FAMILY PLANNING INFORMATION AND EDUCATION

Rising public concern over the occurrence of unintended pregnancy and, particularly, of unintended, nonmarital adolescent pregnancy and childbearing in the United States has drawn attention to the manner in which young people are educated about sexuality, contraception, and how to avoid pregnancy and other negative consequences of sexual activity. Parents and other adults have long played a key role in controlling the sexual behavior of adolescents and in providing basic information about sex and pregnancy avoidance. During the past twenty-five years, there has been a proliferation of organized efforts to augment the information, education, and support traditionally provided by families. Beginning with programs and services for young pregnant women, these efforts have expanded to include legislative mandates regarding the teaching of sexuality or family life education in schools, development and distribution of a variety of sexuality-education curricula, as well as integrated community interventions and media involvement. Organized efforts to implement sexuality education and related activities have also been influenced by growing public concern and awareness of HIV/AIDs and the need to provide young people with the information and means to avoid infection.

Increasingly, policies and programs to encourage abstinence among unmarried teenagers have become popular. Some of these programs attempt to accomplish this objective by giving young people encouragement, offering moral support and teaching interpersonal skills to resist pressures to become sexually active. Others, which seek to convince teenagers that sex before marriage is immoral, emphasize the negative consequences of sexual intercourse, occasionally withhold or distort information about the availability and effectiveness of contraception (Alan Guttmacher Institute 1994a). In fact, although most public schools provide some sort of sexuality education to middle or junior and senior high school students, the education provided is often too little, too late.

On a broader scale, community and service organizations have implemented interventions aimed at increasing the life options of disadvantaged young people through, for example, role models and mentoring, community service projects, job training, and activities aimed at reducing risky behaviors. Such interventions are expected indirectly to reduce levels of unintended teenage pregnancy, childbearing, and sexually transmitted infections, based on the belief that teenagers who are more positive about their futures are less likely to participate in risk-taking behaviors, including risky sexual practices.

Other policies or programs implemented with the hope of reducing unprotected teenage sexual behavior include (1) comprehensive school-based sexuality-education curricula that include discussion of abstinence but also include information about contraceptive methods and services; (2) programs that address the social pressures faced by teenagers to have sex and that provide modeling and practice of communication, negotiation, and refusal skills; (3) condom availability programs in schools; and (4) multicomponent programs that include communitywide activities—such as media involvement, social marketing, and links between school-based activities and contraceptive service providers (Alan Guttmacher Institute 1994a).

Evaluations of a variety of programs and approaches aimed at affecting teenage sexual and reproductive behavior, although still somewhat inconclusive, have shown that some programs have had a positive effect on the behavior of youth. In addition, results of multiple studies indicate that the provision of contraceptive information and access does not encourage young people to become sexually active at younger ages. Reviews of the evaluation research point to the need for integrated approaches that both address the antecedents of sexual risk taking (e.g., poverty, violence, social disorganization) and provide young people (who will soon become adults) with the information, skills, and resources to make responsible decisions about sexual behavior and the avoidance of unintended outcomes (e.g., Kirby 1997).

CONTRACEPTIVE SERVICE PROVISION

In the United States, women can receive contraceptive services from private practice general and family practitioners and obstetrician-gynecologists, as well as from publicly supported clinics run by hospitals, health departments, community health centers, and Planned Parenthood affiliates or independent clinic providers. In addition, some teenage and young adult women receive contraceptive services from school-based clinics and college or university health centers.

Private practice physicians are the most numerous providers in the United States that are available to women seeking contraceptive information and services. More than 40,000 family practice doctors and nearly 30,000 obstetriciangynecologists provide office-based outpatient services (Alan Guttmacher Institute 1997). About seven in ten women seeking family planning services report going to a private practitioner or health maintenance organization (HMO) for their care (Aloma et al. 1997).

Annually, some 6.5 million U.S. women receive contraceptive services, supplies, and information from more than 7,000 publicly supported family planning clinics, located in 85 percent of all U.S. counties (Frost 1996). Family planning clinics, using a combination of federal, state, and local funds, provide care to those who cannot afford services from private physicians or who cannot use private physicians for other reasons. In most clinics, fees are based on the client's ability to pay, confidential services to teenagers are assured, and a full range of contraceptive methods are offered. As a result, family planning clinic clients are primarily low-income (57 percent are below 100 percent of the federal poverty level, and 33 percent are between 100 percent and 249 percent of the federal poverty level) and young (20 percent are under age 20; 50 percent are aged 20–29). Although a majority of clinic clients are non-Hispanic whites, nearly 40 percent are minority women (19 percent are black, 14 percent are Hispanic, and 7 percent are Asian or other races) (Frost and Bolzan). Lower-income women go to clinics primarily because they cannot afford physicians' fees, because the clinic is more conveniently located, or because the clinic will accept Medicaid payment. Adolescents often go to clinics because of the free or low-cost services and because they are afraid a private physician will tell their parents about their contraceptive use. In addition, some women, especially teenagers who have never been to a physician on their own, go to clinics because they do not know a physician who would serve them. Clinic clients usually shift to private physicians when their incomes rise and as they become older.

Sixty percent of all publicly supported clinics receive federal Title X support and must therefore follow federal standard of care guidelines. These guidelines provide medical protocols as well as mandates regarding confidentiality and key areas of outreach that clinics should seek to address. As a result, many publicly supported clinics provide outreach and information or education in local schools or in other community locations. These clinics often seek to reach out to women (and men) in need of contraceptive care who have special needs or risk factors for unintended pregnancy (e.g., because of homelessness, drug or alcohol abuse, domestic violence, or other reasons).

The provision of contraceptive services, like all areas of health care, has been affected by changes in the structure of health care financing and the rise of managed care. In the past, most privately insured women had employer-based indemnity health insurance plans that rarely covered either routine gynecological checkups or reversible contraceptive services and supplies. However, such plans often covered sterilization services. Today, most privately insured women are enrolled in managed care plans. These plans are more likely to cover preventative care, including routine gynecological checkups and some reversible contraceptive services and supplies. However, not all managed care plans cover all or even most methods, and often the process of obtaining contraceptive services within managed care plans places additional burdens on women seeking contraceptive care. These burdens include prior authorization requirements that may cause some women to delay care or forgo sensitive care that a woman may not want to disclose to her primary care physician (Alan Guttmacher Institute 1994b, 1996).

INTERNATIONAL COMPARISONS

Women in the United States have both similarities and differences with women throughout the world in their efforts to plan the number and timing of children. In adolescence, American women are somewhat less successful in their attempts to prevent unplanned pregnancies than are young women in most other industrialized countries. Table 5 presents recent birthrates among women aged 15–19 for selected European and North American countries. Although there is no evidence that young women in the United States are more (or less) sexually active than young women in many other industrialized countries, the United States has adolescent birthrates that are nine to ten times higher than the rates for the Netherlands and Sweden and more than twice as high as the rates for Canada, England, and Wales. The factors responsible for these differences are not entirely clear; however, it is likely that they are due in part to differences in the levels of disadvantage among countries, to variation in the family planning education and services provided to youth and to greater or lesser openness regarding sexuality among countries.

In developing countries, young women marry earlier and have children at younger ages than in the United States. More than half of the young women in sub-Saharan Africa bear a child during the teenage years and about one-third of the young women in Asia, North Africa, the Middle East, and Latin America bear children as teens, compared to just one-fifth of teenage women in the United States. Although the situation is improving and the proportion of adolescents using contraception is increasing in many developing countries, few married adolescents use contraceptive methods and high percentages of sexually active unmarried adolescents rely on traditional nonmedical methods, such as withdrawal and periodic abstinence. Greater use of reliable contraceptive methods by adolescents worldwide is often hampered by inadequate or inaccurate information, poor access to services, and community expectations that value early childbearing within marriage and punish sexual activity outside of marriage. As a result, a substantial proportion of births to adolescents are unplanned—40 to 60 percent in several Latin American and sub-Saharan African countries, and 20 percent or more even in countries where almost all births are to married adolescents. By comparison, 66 percent of adolescent births in the United States are unplanned (Alan Guttmacher Institute 1998).

The patterns of pregnancy, childbearing, and contraceptive use among women of all ages vary from region to region throughout the world. Table 6 presents information on pregnancy rates

(per 1,000 women aged 15–44), planning status of pregnancy, abortion, and contraceptive use for women in different regions of the world. Women in Africa experience the highest rates of pregnancy, the lowest percentage of pregnancies aborted, and the highest percentage of married women using no contraceptive method. Although women in the United States have somewhat higher pregnancy rates than women in most of Europe and other North American countries, they have significantly lower pregnancy rates than most of the women in the rest of the world. The percentage of pregnancies that are planned varies considerably among the different regions of the world, from only 25 percent of pregnancies in eastern Europe being planned to 54 percent of African pregnancies being planned. Similarly, there is variation in the percentage of pregnancies that are aborted and in the patterns of contraceptive use. Compared to other regions of the world, the percentage of U.S. pregnancies that are aborted is similar to that in most of Europe and Latin America but less than half the percentage in eastern Europe. In terms of contraceptive use, married women in the United States are more likely than women in most other regions of the world (except for East Asia) to choose sterilization as their method of contraception. Married women in Africa and in Europe (both eastern and western Europe) rarely choose sterilization, and high percentages of Europeans rely on nonmedical methods, such as withdrawal.

Worldwide, only 47 percent of all pregnancies (including miscarriages) are planned and, at the same time, 42 percent of married women are using no method of contraception. In most regions of the world, one-third or more of married women use no method. Ensuring greater information, education, and access to family planning services worldwide has the potential to greatly reduce the level of unplanned pregnancy and abortion.

(see also: Birth and Death Rates; Family Size; Fertility Determinants; Pregnancy and Pregnancy Termination)

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Jennifer J. Frost

Jacqueline E. Darroch