The Best Intentions Unintended Pregnancy and the Well-Being of Children and Families (1995) / Chapter Skim
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Basic Requirements: Contraceptive Knowledge and Access
Basic Requirements: Contraceptive Knowledge and Access
Pages 126-159
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From page 126... ...
This section also considers the adequacy of school-based education and information about contraception. The second issue considered is that access to contraceptive services and supplies particularly for the more effective methods may be limited.
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From page 127... ...
This perspective is developed in more detail in Chapter 6. KNOWLEDGE, SKILLS, AND SCHOOL-BASED EDUCATION One of the explanations most often given for unintended pregnancy is that men and women, especially those who are teenagers, are poorly informed about contraception and related topics in reproductive health.
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From page 128... ...
, for example, conducted a prospective study of 76 sexually active teenaged women securing oral contraceptives at several private family planning clinics, and found that, in general, the young women underestimated the chances of pregnancy in the absence of contraception, and had inaccurate knowledge regarding the effectiveness of various contraceptive methods. In 1991, 247 women (mean age of 30.2 years)
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From page 129... ...
Clinic personnel report, for example, that adverse media coverage of Norplant has led to requests for removal of the implant, even among women who were experiencing no problems (Herman, 19941. Additional material is presented in Chapter 7 suggesting that although the electronic media present copious amounts of sexually enticing material, they rarely air complementary information on how to prevent such consequences of sexual activity as unintended pregnancy or sexually transmitted diseases (STDs)
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From page 130... ...
In sum, there is significant misinformation among both adults and adolescents about the risks and benefits of contraception. This lack of knowledge can limit efforts to obtain contraception and continue using it, thereby increasing the risk of unintended pregnancy.
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From page 131... ...
Most school-based sex education programs can be categorized into one of four types: (1) those that try to increase knowledge about reproductive health and especially about all methods of pregnancy prevention including abstinence, and emphasize the risk and consequences of pregnancy; (2)
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From page 132... ...
Despite the public support and state policies, available school-based information and education about human sexuality in general and contraception in particular are insufficient in a number of ways. First, while it is true that many states require schools to provide sexuality education and HIV/AIDS education to students at different grade levels, it is also the case that in many states, the content of those educational programs is limited by statute or by state policy or both (The Alan Guttmacher Institute, 19891.
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From page 133... ...
For example, a 1987 survey of secondary school sex education teachers found clear evidence of misinformation about various methods of contraception; 77 percent held the erroneous belief that women taking oral contraceptives should stop from time to time to "give the body a rest" (Forrest and Silverman, 19891. A different, slightly dated analysis, the National Longitudinal Survey of Youth (NLSY)
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From page 134... ...
In addition, available data indicate clearly that participation in these sexuality education programs has not been found to encourage adolescents to initiate sexual intercourse, or to increase the frequency of intercourse among adolescents who were sexually active before the program. The sex education programs reviewed by Kirby and colleagues (1994)
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From page 135... ...
ACCESS TO CONI~ACEPIION To what extent is inconsistent or nonuse of contraception, and therefore unintended pregnancy, due to a lack of access to birth control services and supplies? In particular, to what extent is there limited access to the more effective methods of birth control, leading couples to rely on less effective methods which, by definition, have higher failure rates?
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From page 136... ...
An additional analysis that examined adults as well as adolescents elaborated on this observation. The investigators concluded that contraceptive use and, in particular, use of the more effective methods-was favorably affected by such factors as the presence of a national health plan or health care system that includes family planning services and that covers all citizens; the full integration of family planning services into general health care services, rather than such services being separate or specialist-based; the fact that family planning clinics are seen as serving all women, not just those who are poor or adolescent; the availability of free or subsidized supplies (oral contraceptives in particular)
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From page 137... ...
For example, in December 1992 and January 1993, a team from the New York City Mayor's Advisory Council on Child Health called 115 service sites that offer family planning care in the city to request an appointment for contraceptive services; one-third of the callers were not able to make an appointment at all, and the rest confronted significant difficulties and delays. The authors concluded that because the family planning system was so underfunded and poorly organized, access was very limited and that, in addition, succeeding
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From page 138... ...
Data such as these suggest that, in one way or another, most women and men have found ways to secure and use one or more methods of birth control. The problem with this more favorable picture is that even if most people use contraception most of the time, and even if access to the best methods of contraception is more or less adequate in most places, the net result will be an appreciable level of unintended pregnancy, given the relative ease with which pregnancy occurs.
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From page 139... ...
This modest presence of private insurance as a financing source for contraceptive services is consistent with the historic traditions of private-sector health insurance coverage providing coverage of surgical services but not covering preventive care. A 1994 study by The Alan Guttmacher Institute of the coverage of reproductive health services in various insurance and financing plans concluded that although 85 percent or more of typical private health insurance policies cover sterilization services and 66 percent cover abortion, coverage of reversible contraception was appreciably thinner.
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From page 140... ...
Even though HMOs cover a wider range of contraceptive services than do private plans, they nonetheless frequently require copayments for those services, which may serve as a deterrent for some women (The Alan Guttmacher Institute, 19941. In addition, adolescents especially may be reluctant to obtain contraceptive care as a dependent in a managed care setting, fearing that confidentiality will not always be maintained.
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From page 141... ...
Between 1984 and 1991, Medicaid spending for family planning services increased 41 percent and the number of clients served increased 31 percent (Ku, 19931. Nevertheless, as noted earlier, only 7 percent of all family planning visits are covered by Medicaid (Kaeser and Richards, 1994~.
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From page 142... ...
The limited enrollment of adolescents in the Early and Periodic Screening, Diagnosis and Treatment program within Medicaid also suggests that the full potential of this part of the Medicaid program for providing teenagers with contraceptive services, including on-going assessment and counseling, has not yet been realized. Many women with Medicaid coverage, as well as women with neither private health insurance nor Medicaid coverage, secure family planning care through a network of almost 5,500 clinics that obtain an appreciable portion of their funds from public sources, including the Title X program, and the Maternal and Child Health Services Block Grant, as well as the Title XX Social Services Block Grant, and federal, state, and local funds.
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From page 143... ...
The decline in public support, variously measured, is troubling given the evidence that, as Donovan (1991) has noted, clinics are "facing higher costs and sicker patients." For example, the Family Planning Council of Southeastern Pennsylvania reported in 1991 that it now spends more on medicines to treat STDs than on contraceptive methods just the opposite of the case 5 to 8 years ago; and in the state of New York, visits to family planning clinics for treatment of STDs since 1984 have risen almost 80 percent.
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From page 144... ...
at a significantly reduced price to various nonprofit and public family planning programs (e.g., Planned Parenthood, Title X programs, and other public sector clinics) , thereby allowing them to provide OCs to clinic clients at well below market price or provide them for free.
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From page 145... ...
, particularly because the base charge of $365 is often supplemented by additional insertion fees and other charges, which may bring the total to well over $500 or more. Although all 50 states and the District of Columbia offer Medicaid financing for Norplant insertion, many low-income women are not eligible for Medicaid and have no private health insurance coverage.
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From page 146... ...
Accreditation requirements for postgraduate training, established by the Accreditation Council for Graduate Medical Education (ACGME) , are often vague regarding knowledge necessary to offer comprehensive contraceptive services, including adequate counseling and education for various groups who may have special needs.
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From page 147... ...
Some general and family practitioners choose to offer no contraceptive services, and about one in five general and family practitioners does not provide reversible contraceptive services because of such factors as the relatively low pay for such services, religious or moral objections, or simply a discomfort with sexuality and related issues (Orr and Forrest, 19851. A recent Centers for Disease Control and Prevention (1994)
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From page 148... ...
Nurses' effectiveness in promoting health, communicating with patients, adapting medical regimens according to patient preferences and environments, and using community resources make them prime candidates for encouraging contraceptive use as well. A recent survey confirmed their commitment to contraceptive access: a self-administered questionnaire surveying graduates of five reproductive health nurse practitioner programs in the United States revealed that 56 percent of the respondents were currently employed by a Title X agency (National Association of Nurse Practitioners in Reproductive Health, 19941.
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From page 149... ...
For example, less then 20 percent of publicly supported family planning clinics report providing male sterilization services (Burt et al., 1994)
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From page 150... ...
This perspective has not yet been articulated for contraceptive services, even though, just as for i~nmu~z~ations, many opportunuties are present to improve the contraceptive vigilance of adults as well as adolescents. One example is the disinclination of many clinics that screen for and treat STDs to provide contraceptive services.
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From page 151... ...
Although the goals of the program grants could include an emphasis on preventing unintended pregnancy, a recent review of 112 projects receiving CSAP support in 1991 revealed that none had program objectives that included pregnancy prevention, nor did any of the program evaluations focus on this issue (Cartoof, 19941. Although there are many reasons for this state of affairs not the least being that many drug treatment personnel are not trained in this area and have few extra resources to devote to this topic several pilot projects have demonstrated that integration of drug treatment and family planning services is not only possible but also leads to better use of contraception (Armstrong et al., 1991)
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From page 152... ...
This view lies behind the current interest in providing oral contraceptives as over-the
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From page 153... ...
CONCLUSION The data and perspectives presented in this chapter suggest that one of the reasons contraceptive use is inadequate and that unintended pregnancy therefore continues to occur is that Americans have important gaps in their knowledge about contraception in general, and about the risks and benefits of various methods of birth control in particular. The resulting fears and misconceptions can impede the use (including the continuation)
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From page 154... ...
Within the health care community, this may be due to limited training in contraception as well as to such other factors as personal feelings about birth control and concerns about liability. Outside of the health care community, the lack of attention may be due to a sense that contraception is a medical issue, perhaps a touchy subject, or "not part of my job." The net effect of these missed opportunities is that only a limited range of providers and institutions are involved in helping Americans to know about and acquire the means to prevent-Unintended pregnancy.
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From page 155... ...
The effects of sex education on adolescent behavior. Fam Plann Perspect.
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From page 156... ...
Gehshan S The Provision of Family Planning Services in Substance Abuse Treatment Programs.
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From page 157... ...
The association of AIDS education and sex education with sexual behavior and condom use among teenage men. Fam Plann Perspect.
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From page 158... ...
Formal and informal sex education as determinants of premarital sexual behavior. Arch Sex Behav.
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From page 159... ...
Sex education and its association with teenage sexual activity, pregnancy and contraceptive use. Fam Plann Perspect.
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