Encyclopedia of Sociology Vol

factors, also enacted laws enumerating other kinds of forbidden marriages. For example, marriage was prohibited to those not mentally capable of contracting owing to conditions variously labeled as insanity, lunacy, idiocy, feeblemindedness, imbecility, or unsound mind (Clark 1968, pp. 95–96). Marriage was also prohibited to those physically incapable of performing the ‘‘marriage essentials.’’ Generally, this latter criterion involved only the capacity to have ‘‘normal’’ or ‘‘successful’’ sexual intercourse, not necessarily the ability to procreate. As one author explained it, ‘‘Copula, not fruitfulness, is the test’’ (Tiffany 1921, p. 29).

Eugenics also justified, scientifically, laws that prohibited people with certain diseases (e.g., epilepsy, tuberculosis, and venereal disease) and statuses (e.g., habitual criminal, rapist) from marrying. In most cases, such obstacles could be overcome only if the person consented to sterilization. Many believed such statutes were necessary to ‘‘prevent the demise of civilized-society’’ (Linn and Bowers 1978, p. 629). Even some of the most respected legal thinkers joined the eugenicists. Justice Oliver Wendell Holmes of the United States Supreme Court, for example, wrote that it would be ‘‘better for all the world, if instead of waiting to execute degenerate offspring for crimes, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind’’ (Buck v. Bell, 274 U.S. 200 [1927]).

The most notorious marriage impediment was race. By 1930, thirty states had enacted statutes prohibiting interracial marriages (Clark 1968, p. 91). For the most part, these antimiscegenation laws forbade marriages between whites and blacks, but in several cases the prohibition was extended to, for example, white and Malays, whites and Mongolians, whites and Native Americans, and blacks and Native Americans (Kennedy 1959, pp. 59–69).

Divorce was even more strictly regulated than marriage. However, the absence of ecclesiastical restrictions made divorces much easier to obtain in the United States than in England. This was especially true in the northern states. A few states even allowed divorce simply where the cause

seemed ‘‘just and reasonable.’’ Connecticut, for example, permitted divorce for conduct that ‘‘permanently destroys the happiness of the petitioner and defeats the purpose of the marriage relation’’ (Clark 1968, p. 283). During the latter part of the nineteenth century such generous statutes were repealed, and divorce was allowed only in response to specific types of fault—usually adultery, desertion, cruelty, or long-term imprisonment.

Despite stringent regulation of entrance to and exit from marriage, husbands and wives in intact marriages were generally protected from legal scrutiny. Indeed, traditionally, the principle of nonintervention was so strong that neither husbands nor wives could invoke the law to resolve marital disputes even when they wished to. In one case, for example, the wife of a well-to-do but stingy husband asked the Nebraska courts to require him to pay for indoor plumbing and to provide a reasonable allowance to her. The court agreed that, given his ‘‘wealth and circumstances,’’ the husband’s attitude ‘‘leaves little to be said in his behalf.’’ But, said the court, ‘‘the living standards of a family are a matter of concern to the household and not for the courts to determine’’ (McGuire v. McGuire, 157 Neb. 226, 59 N.W.2d 336 [1953]). Similarly, the courts preferred a hands-off approach to parent–child relationships. As the United States Supreme Court ruled in 1944, ‘‘the custody, care, and nurture of the child reside first in the parents, whose primary function and freedom include preparation for obligations the state can neither supply nor hinder. . . . It is in recognition of this that [earlier] decisions have respected the private realm of family life which the state cannot enter’’ (Prince v. Massachusetts, 321 U.S. 158 [1944]).

The extent of the courts’ reluctance to intervene in family matters or, as it was sometimes put, to ‘‘disrupt family harmony,’’ was shown in the rule that spouses could not sue one another for personal torts or injuries. If, for example, a husband assaulted or battered his wife, she was enjoined from taking legal action against him in civil court (Keeton et al. 1984, pp. 901–902). In theory, the husband could be prosecuted in criminal court, but police and criminal courts too were reluctant to interfere in domestic matters (Pleck 1987, p. 187).

The practice of nonintervention was carried a step further at the turn of the century when the courts invented the doctrine of ‘‘parental immunity.’’ Owing to reasons of ‘‘sound public policy, designed to subserve the repose of families and the best interests of society’’ (Hewellette v. George, 68 Miss. 703, 9 So. 885 [1891]), an unemancipated minor was barred from suing his or her parents for negligent or intentional wrongdoing.

Owing to the state’s reluctance to intervene, the family has had a great deal of autonomy in this country, even to the extent that some have referred to the family as a ‘‘minisovereignty’’ (O’Donnell and Jones 1982, p. 7). In recent times, this autonomy has been justified on the basis of privacy rights. Speaking of the married couple’s right to make decisions about the use of contraception, the United States Supreme Court said in 1965, for example, ‘‘we deal with a right of privacy older than the Bill of Rights’’ (Griswold v. Connecticut, 381 U.S. 479 [1965]).

But things began to change in the late twentieth century. First, beginning in the 1960s, strict regulation of entrance to and exit from marriage began to unravel. In the 1967 case of Loving v. Virginia, the United States Supreme Court ruled unconstitutional all antimiscegenation laws, saying that the states had no right to ‘‘prevent marriages between persons solely on the basis of racial classification.’’ ‘‘Marriage,’’ said the Court, ‘‘is one of the ‘basic civil rights of man,’ fundamental to our very existence and survival’’ (388 U.S. 1; quoting Skinner v. Oklahoma, 316 U.S. 535 [1942]). Since Loving, many other marriage restrictions have been repealed or eased. Age requirements in many states have been lowered; the mental ability needed to contract marriage has been ruled to be less than that required for other sorts of contracts; and the necessary mental competency is presumed to be present unless there is ‘‘clear and definite’’ proof to the contrary. Moreover, ‘‘there is a trend in modern times to abolish affinity restrictions’’ (Wardle et al. 1988, § 2:09); only one state (Missouri) still prohibits epileptics to marry (Wardle et al. 1988, § 2:47), and in many states, even prison inmates are deemed to have a right to marry (In re Carrafa, 77 Cal. App.3d 788 [1978]).

These changes reflect the courts’ willingness to protect the rights of individuals to make their own choices about marriage and related matters. The decision to marry, according to the Supreme Court, is among ‘‘the personal decisions protected by the right to privacy’’ (Zablocki v. Redhail, 434 U.S. 374 [1978]).

Presumably, much the same can be said about the decision to divorce; recent changes in divorce laws have, if anything, been even more dramatic than changes in marriage laws. Implicitly accepting the principle that there is a right to divorce, the Supreme Court ruled in 1971 that welfare recipients could not be denied access to divorce courts because they could not afford to pay court costs and fees (Boddie v. Connecticut, 101 U.S. 371 [1971]). By the mid-1980s, every state had either replaced fault-based divorce laws with no-fault laws or added no-fault grounds to existing laws (Freed and Walker 1986, p. 444). No longer, then, must there be a ‘‘guilty’’ and an ‘‘innocent’’ party in a divorce. Instead, one spouse simply needs to assert that the couple is no longer getting along or has been living apart for a certain amount of time.

While regulations governing entrance to and exit from marriage and family life have decreased, there has been a corresponding increase in regulations affecting relations in ongoing families. Spousal immunity has been abolished in most states. Moreover, in many states the law recognizes the crime of ‘‘marital rape.’’ Similarly, children now have more rights that can be asserted against their parents. For example, minors have the right to obtain information about and to use birth control without a parent’s consent (Carey v. Population Services International, 431 U.S. 678 [1977]); to receive psychiatric care (In re Alyne E., 113 Misc. 2d 307, 448 N.Y.S.2d 984 [1982]); and perhaps even to separate from their parents should the parents and children prove ‘‘incompatible’’ (In re Snyder, 85 Wash. 2d 182. 532 P.2d 278 [1975]). At base, says the Supreme Court, children ‘‘are ‘persons’ under the Constitution’’ and have rights that should be protected by the state (Tinker v. Des Moines Independent School District, 393 U.S. 503 [1969]).

Both the easing of marriage and divorce restrictions and the loss of family autonomy can be

traced to the growth of individual rights that began in the 1960s. The idea of family autonomy and privacy and, hence, the policy of nonintervention were traditionally based on ‘‘paternal’’ authority; the authority of the family patriarch. This pattern can be traced back to the Roman idea of patria potestas—or the right of the father to exert absolute control over his family, including the power of life or death.

Family autonomy and privacy that is based on paternal power is viable only when other members of the family are unable to invoke the power of the state against the father. It was for this reason, then, that traditionally the woman’s power to invoke the law was suspended from the moment of her marriage (Blackstone [1769] 1979, Vol. 1, p. 430). Children, likewise, had no legal standing until they reached the age of majority.

Things are much different today: While children still have many ‘‘legal disabilities,’’ they can no longer be regarded as chattel. Women have achieved at least technical legal equality (though whether this has served to their advantage in divorce law is still subject to debate—compare Weitzman 1985 and Jacob 1988). Although the courts still speak of ‘‘family privacy,’’ it is becoming clear that such privacy is based on family members’ individual rights and exists only as long as family members are not in serious conflict about how they wish to assert those rights.

Some mourn the loss of near total family autonomy; the family, they say, has lost its integrity (Peirce 1988). There is no doubt that the notion of family autonomy or privacy served an important value: It has been ‘‘a convenient way for dealing with a problem . . . [that is] especially acute in the United States—that of devising family law that is suited to the needs and desires of persons with different ethnic and religious backgrounds, different social status, and different standards of living’’ (Glendon 1989, p. 95). In many instances, however, nonintervention created private Hobbesian jungles in which the strong ruled and the weak could not call upon the law for help.

As we move into the twenty-first century, families will continue to play an important role in

society, and there can be little doubt that family relations will continue to be regarded as legally different from other relations and worthy of special legal protection. The question is, To whom is the law’s protection to be extended in domestic matters as the United States embarks upon the twenty-first century? Traditionally, lawmakers have extended this protection to a limited variety of relations—the father–mother–children household. If present trends continue, however, the traditional ideal-typical nuclear family will be something that is achieved (and perhaps aspired to) by only a small fraction of Americans (Difonzo 1997; Estlund and Nussbaum 1998; McIntyre and Sussman 1995; Reagin 1999).

As we move through the first decades of this new century, new and more complex family legal issues will emerge as people construct new communal arrangements, call them family, and seek the protections accorded by the law to more traditional arrangements (Dolgin 1999; Edwards 1999; Minow 1993). The most pressing question facing lawmakers is this: Will the law continue to afford its protections only to those domestic arrangements that mirror traditional family forms, or will it embrace and protect domestic arrangements insofar as they fulfill traditional family functions?

(SEE ALSO: Family and Household Structure)

REFERENCES

Blackstone, William (1769) 1979 Commentaries on the Laws of England, 4 vols. Chicago: University of Chicago Press.

Clark, Homer H., Jr. 1968 Law of Domestic Relations. St. Paul, Minn.: West.

———1980 Cases and Problems on Domestic Relations. 3rd ed. St. Paul, Minn.: West.

Difonzo, J. Herbie 1997 Beneath the Fault Line: The Popular and Legal Culture of Divorce in the Twentieth Century. Charlottesville: University Press of Virginia.

Dolgin, Janet L. 1999 Defining the Family: Law, Technology and Reproduction in an Uneasy Age. New York: New York University Press.

Edwards, Jeanette 1999 Technologies of Procreation: Kinship in the Age of Assisted Conception. New York: Routledge.

Estlund, David M. and Martha C. Nussbaum 1998 Sex, Preference, and Family: Essays on Law and Nature. New York: Oxford University Press.

Freed, Doris J., and Timothy B. Walker 1986 ‘‘Family Law in the Fifty States: An Overview.’’ Family Law Quarterly 20:439–587.

Glendon, Mary A. 1989 The Transformation of Family Law, State, Law, and Family in the United States and Western Europe. Chicago: University of Chicago Press.

Grossberg, Michael 1985 Governing the Hearth: Law and Family in Nineteenth-Century America. Chapel Hill: University of North Carolina Press.

Jacob, Herbert 1988 Silent Revolution. Chicago: Univer-

sity of Chicago Press.

Keeton, W. Page, Dan B. Dobbs, Robert E. Keeton, and David G. Owen 1984 Prosser and Keeton on the Law of Torts, 5th ed. St. Paul, Minn.: West.

Kennedy, Stetson 1959 The Jim Crow Guide to the USA. London: Lawrence and Wishart.

Linn, Brian J., and Lesly A. Bowers 1978. ‘‘The Historical Fallacies Behind Legal Prohibitions of Marriages Involving Mentally Retarded Persons: The Eternal Child Grows Up.’’ Gonzaga Law Review 13:625–690.

Long, Joseph R. 1905 A Treatise on the Law of Domestic Relations. St. Paul, Minn.: Keefe-Davidson.

McIntyre, Lisa J. and Marvin Sussman 1995 Families and Law. New York: Haworth Press.

Minow, Martha 1993 Family Matters: Readings on Family Lives and the Law. New York: New Press.

O’Donnell, William J., and David A. Jones 1982 The Law of Marriage and Marital Alternatives. Lexington, Mass.: D. C. Heath.

Peirce, Dorothy S. 1988 ‘‘BRI v. Leonard: The Role of the Courts in Preserving Family Integrity.’’ New England Law Review 23:185–219.

Pleck, Elizabeth 1987 Domestic Violence: The Making of American Social Policy Against Family Violence from Colonial Times to the Present. New York: Oxford University Press.

Pollock, Frederick, and Frederic W. Maitland 1898 The History of English Law Before the Time of Edward I, 2 vols. Cambridge: Cambridge University Press.

Reagin, Milton C. Alone Together: Law and the Meanings of Marriage. New York: Oxford University Press.

tenBroek, Jacobus 1964 Family Law and the Poor. Westport, Conn.: Greenwood.

Tiffany, Walter C. 1921 Handbook on the Law of Personal and Domestic Relations. 3rd ed. St. Paul, Minn.: West.

Wardle, Lynn D., Christopher L. Blakesley, and Jacqueline Y. Parker 1988 Contemporary Family Law: Principles, Policy, and Practice, 4 vols. Deerfield, Ill.: Callaghan.

Weitzman, Lenore 1985 The Divorce Revolution. New

York: Free Press.

LISA J. MCINTYRE

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

Percentage of All Pregnancies (Excluding Miscarriages) That are Unintended by Women’s Age, Marital Status, Race, Ethnicity and Poverty Status, 1987 and 1995

Table 2

SOURCE: *Forrest (1994); **Henshaw (1998).

NOTE: na=not available.

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-in- come 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,

Estimated Percentage of Women Who Would Experience a Contraceptive Failure During the First Twelve Months of Perfect Method Use* and the Corrected Use-failure Rates Given Typical Method Use** for all Users and for Age, Poverty, and Marital Status Subgroups of Women Experiencing the Lowest or Highest Use-failure Rates

Table 4

SOURCES: *Trussell (1998), Table 31–1, p. 800. The ranges presented correspond to different formulations of the method, except for the cervical cap, where the range is due to woman’s parity status. **Fu et al., (1999), (From corrected Table 1, available on http://www.agi-usa.org/pubs/journals/ 3105699.html).

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). Low- er-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