This thing called marriage.

No one talks about the unnecessary arguments. No one talks about the irritations. No one talks about the sudden disgust for everything your partner does. No one talks about the nagging, the complaints. No one talks about how the person begins to piss you off. 

No one talks about how he or she doesn't look attractive anymore. No one talks about how it feels like you have a stranger in your house.

No body talks about how he or she can't provide the usual anymore, and how we can't cope with it. Nobody talks about the storms that come. The sickness, the brokeness. 

So we don't prepare for these things. And when the storm comes, we believe it to be the end.

But there's always a calm after every storm. 

There's always imperfections. There's always that strangeness. There's always time for everything that I mentioned. The hurricane is strong enough to carry you, but when you and your partner are well prepared, you'll be stronger and you'll win.

Eunice Idowo

Overview of Family Planning .

According to the Centers for Disease Control and Prevention (CDC), family planning is one of the 10 great public health achievements of the twentieth century, on a par with such accomplishments as vaccination and advances in motor vehicle safety (CDC, 1999). The ability of individuals to determine their family size and the timing and spacing of their children has resulted in significant improvements in health and in social and economic well-being (IOM, 1995). Smaller families and increased child spacing have helped decrease rates of infant and child mortality, improve the social and economic conditions of women and their families, and improve maternal health. Contemporary family planning efforts in the United States began in the early part of the twentieth century. By 1960, modern contraceptive methods had been developed, and in 1970 federal funding for family planning was enacted through the Title X program, the focus of this report.

This chapter provides an overview of family planning in the United States. It begins by explaining the importance of family planning services and the crucial needs they serve. Next is a review of milestones in family planning, including its legislative history. The third section provides data on the use of family planning services. This is followed by a discussion of the changing context in which these services are provided, including changes in the populations served by Title X, changes in technology and costs, the growing evidence base for reproductive health services, and social and cultural factors. The fifth section addresses the financing of family planning. The final section presents conclusions.

WHY FAMILY PLANNING IS IMPORTANT

According to the World Health Organization (WHO), family planning is defined as “the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility” (working definition used by the WHO Department of Reproductive Health and Research [WHO, 2008]). The importance of family planning is clear from its benefits to individuals, as well as to families, communities, and societies (AGI, 2003). Family planning serves three critical needs: (1) it helps couples avoid unintended pregnancies; (2) it reduces the spread of sexually transmitted diseases (STDs); and (3) by addressing the problem of STDs, it helps reduce rates of infertility.

These benefits are reflected in the federal government’s continued recognition of the contribution of family planning and reproductive health to the well-being of Americans. Responsible sexual behavior is one of the 10 leading health indicators of Healthy People 2010, a set of national health objectives whose goal is to increase the quality of life and years of healthy life. The Healthy People indicators reflect major public health concerns. The United States has set a national goal of decreasing the percentage of pregnancies that are unintended from 50 percent in 2001 to 30 percent by 2010 (HHS, 2000). The objectives for increasing responsible sexual behavior are to increase the proportion of adolescents who abstain from sexual intercourse or use condoms if currently sexually active, and to increase the proportion of all sexually active persons who use condoms.

The 2007–2012 Department of Health and Human Services (HHS) Strategic Plan is intended to provide direction for the Department’s efforts to improve the health and well-being of Americans. The provision of family planning services promotes several HHS goals, including increasing the availability and accessibility of health care services, preventing the spread of infectious diseases (through testing for STDs/HIV), promoting and encouraging preventive health care, and fostering the economic independence and social well-being of individuals and families. The contribution of Title X to these goals is discussed in Chapter 3.1

Finding 2-1. The provision of family planning services has important benefits for the health of individuals, families, communities, and societies. There is a continued need for investment in family planning and related reproductive health services, particularly for those who have difficulty obtaining these important services.

Avoiding Unintended Pregnancy

The ability to time and space children reduces maternal mortality and morbidity by preventing unintended and high-risk pregnancies (World Bank, 1993; Cleland et al., 2006). Unintended pregnancy is associated with an increased risk of morbidity for the mother and with health-related behaviors during pregnancy, such as delayed prenatal care, tobacco use, and alcohol consumption, that are linked to adverse effects for the child. According to the Institute of Medicine (IOM) report The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families:

The child of an unwanted conception especially (as distinct from a mistimed one) is at greater risk of being born at low birth weight, of dying in its first year of life, of being abused, and of not receiving sufficient resources for healthy development. The mother may be at greater risk of depression and of physical abuse herself, and her relationship with her partner is at greater risk of dissolution. Both mother and father may suffer economic hardship and may fail to achieve their educational and career goals. Such consequences undoubtedly impede the formation and maintenance of strong families. (IOM, 1995, p. 1)

In 2000, approximately half of unintended pregnancies resulted in abortion (Finer and Henshaw, 2006); thus the availability and appropriate use of contraception can also reduce abortion rates (AGI, 2003).2 In addition to preventing unintended pregnancies, effective use of contraceptives (latex condoms) can reduce the transmission of STDs (see the discussion below).

When children are adequately spaced (with conception taking place no sooner than 18 months after a live birth, or about 2.5 years between births), they are less likely to suffer complications. Such complications include low birth weight, which is associated with a host of health and developmental problems (Conde-Agudelo et al., 2006). Low birth weight and premature birth are more likely to occur to women under 18 and over 35, and to those who have already had four or more births (WHO, 1994).

In addition to its maternal and infant health benefits, family planning can increase the involvement of partners in decisions about whether and when to have children. One of the most important aspects of helping people plan for pregnancy is helping them avoid unintended pregnancy. Couples who are able to plan their families experience less physical, emotional, and financial strain; have more time and energy for personal and family development; and have more economic opportunities (Cleland et al., 2006). In turn, effective family planning results in fewer strains on community resources, such as social services and health care systems (WHO, 1994).

According to the IOM report cited above, women are considered at risk of unintended pregnancy if they “(1) have had sexual intercourse; (2) are fertile, that is, neither they nor their partners have been contraceptively sterilized and they do not believe that they are infertile for any other reason; and (3) are neither intentionally pregnant nor have they been trying to become pregnant during any part of the year” (IOM, 1995, p. 28). Among the nearly 50 million sexually active women aged 18–44, 28 million (56 percent) are at risk of unintended pregnancy (Frost et al., 2008a). Given that the onset of sexual activity increasingly occurs before marriage, when the proportion of pregnancies that are unintended is greatest (see below), the highest proportion of women at risk of unintended pregnancy is found among those aged 18–29 (70 percent), although a significant proportion of women aged 30–44 (40 percent) are also at risk (IOM, 1995).

While significant advances have been made in contraceptive technology and the availability of family planning services, rates of unintended pregnancy in the United States remain high, particularly for certain segments of the population. In 2001, 49 percent of pregnancies were unintended, a rate that had not changed since 1994 (Finer and Henshaw, 2006). In 2001, unintended pregnancies resulted in 1.4 million births, 1.3 million induced abortions, and an estimated 400,000 miscarriages (Frost et al., 2008a). Notably, the United States has high rates of unintended pregnancy compared with other developed countries. For example, the percentage of unintended pregnancies in France is 33 percent and in Scotland 28 percent (Trussell and Wynn, 2008). Unintended pregnancies result in societal burden, and significant economic savings are realized through investment in family planning services. The Guttmacher Institute has estimated that every $1.00 invested in helping women avoid unwanted pregnancies saved $4.02 in Medicaid expenditures (Frost et al., 2008b).

A variety of factors contribute to unintended pregnancy, including lack of access to contraception, failure of chosen contraceptive methods, less than optimal patterns of contraceptive use or lack of use, and lack of adequate motivation to avoid pregnancy (Frost et al., 2008a). The reasons for the high rate of unintended pregnancies in the United States, particularly in relation to rates in other industrialized countries, are poorly understood. A better understanding of these reasons from the perspective of current, former, and potential users of family planning services is needed (see Chapter 5 for discussion of the need for better data collection systems to capture client perspectives).

Unintended pregnancy is most likely among women who are young, unmarried, low-income, and/or members of racial or ethnic minorities (see Figures 2-1 through 2-3, respectively), although it occurs in significant numbers across demographic groups (IOM, 1995). Teenagers and young adults aged 18–24 have the highest rates of unintended pregnancy—more than one intended pregnancy occurred for every 10 women in this age range, which is twice the rate for women overall (Finer and Henshaw, 2006). Unsurprisingly, unintended pregnancies represent the highest proportion of all pregnancies among teenagers and young adults as well, ranging from 100 percent for those under 15, to 82 percent among those aged 15–19, to 60 percent among those aged 20–24 (Finer and Henshaw, 2006). However, teenage pregnancy rates dropped 38 percent between 1990 and 2004, from 116.8 per 1,000 to 72.2 per 1,000 among those aged 15–19 (NCHS, 2008). The pregnancy rate dropped more sharply among teenagers aged 15–17 (from 77.1 per 1,000 in 1990 to 41.5 in 2004, a 46 percent decline) than among those aged 18–19 (167.7 per 1,000 to 118.6 per 1,000, a 29 percent decline). The teenage birth rate also declined over the past two decades, from a peak of 61.8 per 1,000 in 1991 to 40.5 per 1,000 in 2005, a 35 percent decrease. The birth rate among teenagers aged 15–19 increased 3 percent between 2005 and 2006, to 41.9 per 1,000 (NCHS, 2008). Teenage pregnancy rates are currently available only through 2004, but preliminary data suggest that there may also have been an increase in the teen pregnancy rate between 2005 and 2006 (The National Campaign, 2009