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# 9 {#section .Chapter-#}

# Family Planning

Lead Agency: Office of Population Affairs

### Contents {#contents .Heading-Special}

[Goal Page 9-3](#goal)

[Overview Page 9-3](#overview)

[Issues and Trends Page 9-3](#issues-and-trends)

[Disparities Page 9-6](#disparities)

[Opportunities Page 9-7](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
9-8](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
9-10](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
9-11](#healthy-people-2010-objectives)

[Related Objectives From Other Focus Areas Page
9-30](#related-objectives-from-other-focus-areas)

[Terminology Page 9-31](#terminology)

[References Page 9-32](#references)

##   {#section-1 .unnumbered}

## Goal

**Improve pregnancy planning and spacing and prevent\
unintended pregnancy.**

## Overview

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

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

Unintended pregnancy rates in the United States show a decline, probably
as a result of higher contraceptive use and use of more effective
contraceptive methods.Error: Reference source not found Despite this
improvement, unintended pregnancy remains a common problem, and further
progress is needed.

### Issues and Trends

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

No one method of contraception is likely to be consistently and
continuously suitable for each woman, man, or couple. Total abstinence
is the only fool-proof method of contraception. Sterilization, the most
common method of contraception in the United States, has near-perfect
effectiveness and differs from other methods because it is usually
permanent.Error: Reference source not found

Used by an estimated 10 million females, combination oral contraceptives
are the most popular method of reversible contraception in the United
States. Other hormonal contraceptives, such as injectables and implants,
and intrauterine devices (IUDs) have the appeal of providing effective
contraception without the need for daily compliance. For barrier
methods, such as the condom and diaphragm, the average effectiveness is
more variable. Used correctly and consistently, condoms can prevent both
pregnancy and disease. Other barrier methods include the diaphragm,
cervical cap, and female condom, which may reduce the risk but do not
prevent sexually transmitted diseases (STDs) that primarily affect the
cervix. Spermicides used alone (foams, creams, and jellies), coitus
interruptus (withdrawal), and periodic abstinence (calendar rhythm) are
other options; however, their effectiveness in actual use is lower than
that for other methods.![](media/image2.wmf){width="4.497916666666667in"
height="5.326388888888889in"}

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

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

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

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

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

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

Abortion results when women have unintended pregnancies, and adequate
access to family planning services reduces the number of unintended
pregnancies. Each year, publicly subsidized family planning services
prevent an estimated 1.3 million unintended pregnancies.[^17] For every
\$1 spent on publicly funded contraceptive services, \$3 is saved in
Medicaid bills for pregnancy-related health care and medical care for
newborns.Error: Reference source not found

### Disparities

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

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

An estimated 6.6 million females receive services from subsidized family
planning providers annually, slightly less than one-half of those
considered to be in need of subsidized family planning services (those
at risk of unintended pregnancy and with a family income less than 250
percent of the poverty level).[^19] Family planning programs consisting
of some 3,000 agencies with over 7,000 clinic locations provide nearly
40 percent of family planning services in the United States. Health
departments represent nearly half of these locations, along with
hospitals, community health centers, and other public and nonprofit
organizations. Nearly two-thirds of all females served (4.2 million)
obtained care at 1 of 4,200 clinics receiving funds from the Federal
Title X Family Planning Program.Error: Reference source not found

### Opportunities

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

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

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

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

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

## Interim Progress Toward Year 2000 Objectives

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

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

## Healthy People 2010---Summary of Objectives

### Family Planning {#family-planning-1 .Heading-Special-Sub}

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

  ------------ --------------------------------------------------------------
  **Number**   **Objective Short Title**

  9-1          Intended pregnancy

  9-2          Birth spacing

  9-3          Contraceptive use

  9-4          Contraceptive failure

  9-5          Emergency contraception

  9-6          Male involvement in pregnancy prevention

  9-7          Adolescent pregnancy

  9-8          Abstinence before age 15 years

  9-9          Abstinence among adolescents aged 15 to 17 years

  9-10         Pregnancy prevention and sexually transmitted disease\
               (STD) protection

  9-11         Pregnancy prevention education

  9-12         Problems in becoming pregnant and maintaining a pregnancy

  9-13         Insurance coverage for contraceptive supplies and services
  ------------ --------------------------------------------------------------

## Healthy People 2010 Objectives

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

**Target:** 70 percent.

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

**Target setting method:** Better than the best.

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

Note: The table below may continue to the following page.

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

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

A significant decline in the rates of unintended pregnancy has occurred,
indicating that progress toward a goal of increased intended pregnancy
is possible. Between 1987 and 1994, the proportion of pregnancies that
were unintended declined from 57 to 49 percent.Error: Reference source
not found By comparison, the percentage of unintended pregnancy is much
lower in some other countries---in 1994--95, it was 39 percent in Canada
and 6 percent in the Netherlands.Error: Reference source not found
Overall, females in the United States spend three-fourths of their
reproductive years trying to avoid pregnancy.Error: Reference source not
found Unintended pregnancy often is mistakenly perceived as
predominantly an adolescent problem; however, unintended pregnancy is a
problem among all reproductive age groups. In 1994, nearly one-half (48
percent) of females aged 15 to 44 years had at least one unintended
pregnancy in their lifetime, more than one-fourth (28 percent) had one
or more unplanned births, nearly one-third (30 percent) had one or more
abortions, and 1 in 10 (11 percent) had both an unintended birth and an
induced abortion.Error: Reference source not found A goal of 70 percent
is ambitious and will require strategies to reduce the gaps among
population groups.

9-2. Reduce the proportion of births occurring within 24 months of a
previous birth.

**Target:** 6 percent.

**Baseline:** 11 percent of females aged 15 to 44 years gave birth
within 24 months of a previous birth in 1995.

**Target setting method:** Better than the best.

**Data source:** National Survey of Family Growth (NSFG), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Females Aged 15 to 44 Years, 1995**          | **New Birth\        |
|                                                | Occurred Within\    |
|                                                | 24 Months of\       |
|                                                | Previous Birth**    |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 11                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 14                  |
+------------------------------------------------+---------------------+
| > White                                        | 10                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 14                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 10                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 14                  |
+------------------------------------------------+---------------------+
| > White                                        | 10                  |
+------------------------------------------------+---------------------+
| **Family income level** (aged 20 to 44 years)  |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 20                  |
+------------------------------------------------+---------------------+
| > Near poor                                    | 11                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 7                   |
+------------------------------------------------+---------------------+
| **Disability status**                          |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | DNC                 |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | DNC                 |
+------------------------------------------------+---------------------+
| **Select populations**                         |                     |
+------------------------------------------------+---------------------+
| ######### Age groups                           |                     |
+------------------------------------------------+---------------------+
| > 15 to 19 years                               | 9                   |
+------------------------------------------------+---------------------+
| > 20 to 24 years                               | 14                  |
+------------------------------------------------+---------------------+
| > 25 to 29 years                               | 10                  |
+------------------------------------------------+---------------------+
| > 30 to 34 years                               | 11                  |
+------------------------------------------------+---------------------+
| > 35 to 39 years                               | 10                  |
+------------------------------------------------+---------------------+
| > 40 to 44 years                               | DSU                 |
+------------------------------------------------+---------------------+
| ######## Marital status                        |                     |
+------------------------------------------------+---------------------+
| > Currently married                            | 11                  |
+------------------------------------------------+---------------------+
| > Formerly married                             | 13                  |
+------------------------------------------------+---------------------+
| > Never married                                | 11                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Encouraging females of all ages to space their pregnancies adequately
can help lower their risk of adverse perinatal outcomes. To the extent
that very closely spaced pregnancies are unplanned, unintended pregnancy
may increase the risk of low birth weight.Error: Reference source not
found A recent study indicates that females who wait 18 to 23 months
after delivery before conceiving their next child lower their risk of
adverse perinatal outcomes, including low birth weight, preterm birth,
and small-for-size gestational age.[^24] Health care providers can help
all new mothers understand that they can become pregnant again soon
after delivery and should assist them with contraceptive education and
supplies.

For adolescents, bearing a child is associated with poor outcomes for
young females and their children. Giving birth to a second child while
still a teen further increases these risks. The prevention of second and
subsequent births to very young females is of great interest to public
health. Research has shown that such births are associated with physical
and mental health problems for the mother and the child.[^25] Yet,
analysis indicates that in the 2 years following the first birth,
teenaged mothers have a second birth at about the same rate as other
mothers. In 1997, nearly one in every five births to teenaged mothers
was a birth of second order or higher.[^26]

9-3. Increase the proportion of females at risk of unintended pregnancy
(and their partners) who use contraception.

**Target:** 100 percent.

**Baseline:** 93 percent of females aged 15 to 44 years at risk of
unintended\
pregnancy used contraception in 1995.

**Target setting method:** Total coverage.

**Data source:** National Survey of Family Growth (NSFG), CDC, NCHS.

+------------------------------------------------+---------------------+
| **Females Aged 15 to 44 Years at Risk of\      | **Used\             |
| Unintended Pregnancy, 1995**                   | Contraception**     |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 93                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 90                  |
+------------------------------------------------+---------------------+
| > White                                        | 93                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 91                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 93                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 90                  |
+------------------------------------------------+---------------------+
| > White                                        | 93                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 92                  |
+------------------------------------------------+---------------------+
| > Near poor                                    | 91                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 93                  |
+------------------------------------------------+---------------------+
| **Select populations**                         |                     |
+------------------------------------------------+---------------------+
| ######### Age groups                           |                     |
+------------------------------------------------+---------------------+
| > 15 to 19 years                               | 81                  |
+------------------------------------------------+---------------------+
| > 20 to 24 years                               | 91                  |
+------------------------------------------------+---------------------+
| > 25 to 29 years                               | 94                  |
+------------------------------------------------+---------------------+
| > 30 to 34 years                               | 94                  |
+------------------------------------------------+---------------------+
| > 35 to 39 years                               | 95                  |
+------------------------------------------------+---------------------+
| > 40 to 44 years                               | 93                  |
+------------------------------------------------+---------------------+
| Marital status                                 |                     |
+------------------------------------------------+---------------------+
| > Currently married                            | 95                  |
+------------------------------------------------+---------------------+
| > Formerly married                             | 92                  |
+------------------------------------------------+---------------------+
| > Never married                                | 88                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

The percentage of at-risk females using any form of contraception rose
from 88 in 1982 to 93 in 1995.[^27] Increasing the target to 100 percent
by 2010 will be challenging and could reduce dramatically occurrences of
unintended pregnancy. Poor or nonexistent contraceptive use is one of
the main causes of unintended pregnancy, with unintended pregnancy
occurring among two groups: females using no contraception and females
whose contraceptives fail or are used improperly. In the United States,
the small proportion of females who are at risk of unintended pregnancy
and use no method of contraception account for over half of all
unintended pregnancies. Reducing the proportion of sexually active
persons using no birth control method and increasing the effectiveness
(correct and consistent use) with which persons use contraceptive
methods would do much to lower the unintended pregnancy rate.[^28] Just
reducing the proportion of females not using contraception by half could
prevent as many as one-third of all unintended pregnancies and 500,000
abortions per year.[^29]

9-4. Reduce the proportion of females experiencing pregnancy despite use
of a reversible contraceptive method.

**Target:** 7 percent.

**Baseline:** 13 percent of females aged 15 to 44 years experienced
pregnancy despite use of a reversible contraceptive method in 1995.

**Target setting method:** Better than the best (retain year 2000
target).

**Data sources:** National Survey of Family Growth (NSFG), CDC, NCHS;
Abortion Patient Survey, The Alan Guttmacher Institute.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Females Aged 15 to 44 Years Using\           | **Experienced\      |
| Reversible Contraception, 1995**               | Pregnancy**         |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 13                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNC                 |
+------------------------------------------------+---------------------+
| > White                                        | DNC                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 15                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 20                  |
+------------------------------------------------+---------------------+
| > White                                        | 11                  |
+------------------------------------------------+---------------------+
| ###### Family income level                     |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DSU                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | 18                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 10                  |
+------------------------------------------------+---------------------+
| ###### Disability status                       |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | DNC                 |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | DNC                 |
+------------------------------------------------+---------------------+
| **Select populations**                         |                     |
+------------------------------------------------+---------------------+
| > Marital/cohabiting status                    |                     |
+------------------------------------------------+---------------------+
| > Married                                      | 9                   |
+------------------------------------------------+---------------------+
| > Cohabiting                                   | 22                  |
+------------------------------------------------+---------------------+
| > Unmarried, not cohabiting                    | 14                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

The public health benefits of improved contraceptive practices are
potentially enormous. Whether fertile females who are sexually active
and do not want to get pregnant experience an unintended pregnancy is a
function of their choice---and their partners' choice---of contraceptive
methods and how effectively they use them. The efficacy of reversible
contraceptive methods depends on consistent and appropriate usage.
Unintended pregnancies experienced by females using reversible methods
are primarily a result of inconsistent and/or inappropriate use.[^30]
Ideally, an objective would focus on consistent and correct use of a
particular method. The data, however, cannot address the role that
method switching may play in unintended pregnancy.

9-5. (Developmental) Increase the proportion of health care providers
who provide emergency contraception.

**Potential data source:** The Alan Guttmacher Institute.

The *U.S. Guide to Clinical Preventive ServicesError: Reference source
not found* identifies postcoital administration of emergency
contraceptive pills (ECP) after unprotected intercourse as an effective
means of reducing subsequent pregnancy. ECP is estimated to reduce the
risk of subsequent pregnancy by 75 percent. Yet this method, which has
the public health potential of significantly reducing unintended
pregnancy, is not well known and not yet widely available to the public.
Surveys indicate that knowledge and use of postcoital contraception
remains low among patients and clinicians alike.Error: Reference source
not found In 1995, less than 1 percent of females in the United States
reported ever having used ECP.[^31]

Several developments, however, have formalized recognition within the
medical community of ECP as an effective means of preventing pregnancy,
including the American College of Obstetricians and Gynecologists
issuance of practice guidelines for emergency oral contraception.
Barriers to the more frequent use of ECP include a lack of physician
awareness of the method, a lack of public awareness of the method's
availability, and a lack of access by patients to a physician who will
prescribe the method.[^32] Increased public awareness, including
culturally and linguistically competent education about ECP as well as
direct access to and insurance reimbursement for ECP, would contribute
significantly toward attainment of this objective.

In February 1997, the Food and Drug Administration (FDA) announced that
certain regimens of combined oral contraceptives are safe and effective
for ECP when initiated within 72 hours after unprotected
intercourse.[^33] The FDA notice was intended to encourage manufacturers
to make this additional contraceptive option available.Error: Reference
source not found One product, an emergency contraceptive kit, has been
approved by FDA and is being marketed. On July 28, 1999, FDA approved
the first progestin-only emergency contraceptive.

9-6. (Developmental) Increase male involvement in pregnancy prevention
and family planning efforts.

**Potential data source:** National Survey of Family Growth (NSFG), CDC,
NCHS.

There is increasing recognition of the value of male involvement in
pregnancy prevention and family planning. Several related developments
in public health and welfare demonstrate that male involvement is key,
including culturally and linguistically appropriate programs promoting
condom use and addressing HIV and STD prevention, culturally and
linguistically competent services targeting men as part of managed care
marketing strategies, emphasis on male responsibility in welfare, child
support enforcement, and pregnancy prevention efforts. Concern about the
spread of HIV and other STDs and the recognition of condoms as the most
effective way of preventing transmission during intercourse have
accentuated the need to change the sexual behavior of males. The need
for rapid treatment of male partners of females testing positive for
bacterial STDs is a critical element in slowing not only STD spread but
also that of HIV.

Yet, information about how males could and should participate in
pregnancy prevention programs is lacking. For many years, reproductive
policy in the United States concentrated almost entirely on females. The
National Survey of Adolescent Males (NSAM), begun in 1988 by the Urban
Institute and repeated again in 1995, collected the first national trend
data on the reproductive behavior of male teens. An Urban Institute
survey of publicly funded family planning clinics found that males make
up more than 10 percent of the total clientele in only 13 percent of
clinics. An average of 6 percent of clients are males. Males represent
an even smaller share of clients who receive family planning services
subsidized by the Title X program (2 percent in 1991) or by Medicaid (2
percent in 1990).[^34] Even though males do not actually get pregnant,
integrating them in prevention programs makes sense. Males must be
included in any efforts to address unintended pregnancy.[^35]

The next National Survey of Family Growth (NSFG) is being expanded to
include males, providing an avenue for institutionalizing data
collection about male fertility that will be reflected in the Healthy
People 2010 objectives. Over the course of Healthy People 2010, male
measures for family planning objectives will shift from NSAM to NSFG.
NSFG will be able to collect information from males about sexual
activity, contraceptive use, pregnancies to which they contribute, and
the outcomes of these pregnancies, as well as male perceptions of their
and their partners' views on the intendedness of pregnancies and births.
NSFG will cover a broader range of male age groups than had been covered
under the NSAM, which included only males aged 15 to 19 years.

9-7. Reduce pregnancies among adolescent females.

**Target:** 43 pregnancies per 1,000.

**Baseline:** 68 pregnancies per 1,000 females aged 15 to 17 years
occurred in 1996.

**Target setting method:** Better than the best.

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

Note: The table below may continue to the following page.

+----------------------------------------------------+-----------------+
| **Females Aged 15 to 17 Years, 1996**              | **Pregnancy**   |
+====================================================+=================+
|                                                    | Rate per 1,000  |
+----------------------------------------------------+-----------------+
| > **TOTAL**                                        | 68              |
+----------------------------------------------------+-----------------+
| **Race and ethnicity**                             |                 |
+----------------------------------------------------+-----------------+
| > American Indian or Alaska Native                 | DNC             |
+----------------------------------------------------+-----------------+
| > Asian or Pacific Islander                        | DNC             |
+----------------------------------------------------+-----------------+
| > Asian                                            | DNC             |
+----------------------------------------------------+-----------------+
| > Native Hawaiian and other Pacific Islander       | DNC             |
+----------------------------------------------------+-----------------+
| > Black or African American                        | 124             |
+----------------------------------------------------+-----------------+
| > White                                            | 58              |
+----------------------------------------------------+-----------------+
|                                                    |                 |
+----------------------------------------------------+-----------------+
| > Hispanic or Latino                               | 105             |
+----------------------------------------------------+-----------------+
| > Not Hispanic or Latino                           | 62              |
+----------------------------------------------------+-----------------+
| > Black or African American                        | 128             |
+----------------------------------------------------+-----------------+
| > White                                            | 44              |
+----------------------------------------------------+-----------------+
| **Family income level**                            |                 |
+----------------------------------------------------+-----------------+
| > Poor                                             | DSU             |
+----------------------------------------------------+-----------------+
| > Near poor                                        | DSU             |
+----------------------------------------------------+-----------------+
| > Middle/high income                               | DSU             |
+----------------------------------------------------+-----------------+
| **Disability status**                              |                 |
+----------------------------------------------------+-----------------+
| > Persons with disabilities                        | DNC             |
+----------------------------------------------------+-----------------+
| > Persons without disabilities                     | DNC             |
+----------------------------------------------------+-----------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

The teenage pregnancy rate in the United States is much higher than in
many other developed countries---twice as high as in England and Wales,
France, and Canada and nine times as high as in the Netherlands or
Japan.Error: Reference source not found Teenage pregnancy remains an
intense national issue, within the context of public health and welfare
reform, concerning the optimum potential of the Nation's youth and the
growth and development of newborns. Most adolescent childbearing occurs
outside marriage, a trend that has increased markedly during the past
two decades. In 1997, 78 percent of births to adolescent females (under
age 20 years) were out of wedlock, compared to 44 percent two decades
earlier (1977).Error: Reference source not found

Females under age 15 years experience about 30,000 pregnancies each
year.Error: Reference source not found Consensus is widespread that all
pregnancies in this age group are inappropriate and that ideally the
target number should be zero. Nearly two-thirds of pregnancies in this
age group end in induced abortion or fetal loss. Because of the
relatively small numbers of events (and small sample sizes for fetal
losses) involved, the resulting rates are not as stable as for older
females. Almost no discernible decline in pregnancy rates for this age
group occurs on an annual basis. Therefore, baseline and target data for
pregnancies among adolescents under age 15 years are not included in
this objective.[^36]

9-8. Increase the proportion of adolescents who have never engaged in
sexual intercourse before age 15 years.

Target and baseline:

+-------------+-------------------------------+-----------+-----------+
| Objective   | Increase in Adolescents Aged  | 1995\     | 2010\     |
|             | 15 to 19 Years Never Engaging | Baseline  | Target    |
|             | in Sexual Intercourse Before  |           |           |
|             | Age 15 Years                  |           |           |
+-------------+-------------------------------+-----------+-----------+
|             |                               | ######    |           |
|             |                               | # Percent |           |
+-------------+-------------------------------+-----------+-----------+
| **9-8a.**   | Females                       | 81        | 88        |
+-------------+-------------------------------+-----------+-----------+
| **9-8b.**   | Males                         | 79        | 88        |
+-------------+-------------------------------+-----------+-----------+

**Target setting method:** Better than the best.

**Data sources:** Females---National Survey of Family Growth (NSFG),
CDC, NCHS; Males---National Survey of Adolescent Males (NSAM), Urban
Institute.

+------------------------------------+----------------+----------------+
| **Adolescents Aged 15 to 19 Years, | **No           |                |
| 1995**                             | Intercourse    |                |
|                                    | Before Age 15  |                |
|                                    | Years**        |                |
+====================================+================+================+
|                                    | **9-8a.\       | **9-8b.\       |
|                                    | Females**      | Males**        |
+------------------------------------+----------------+----------------+
|                                    | Percent        |                |
+------------------------------------+----------------+----------------+
| > **TOTAL**                        | 81             | 79             |
+------------------------------------+----------------+----------------+
| **Race and ethnicity**             |                |                |
+------------------------------------+----------------+----------------+
| > American Indian or Alaska Native | DSU            | DSU            |
+------------------------------------+----------------+----------------+
| > Asian or Pacific Islander        | DSU            | DSU            |
+------------------------------------+----------------+----------------+
| > Asian                            | DSU            | DNC            |
+------------------------------------+----------------+----------------+
| > Native Hawaiian and other\       | DSU            | DNC            |
| > Pacific Islander                 |                |                |
+------------------------------------+----------------+----------------+
| > Black or African American        | 70             | 50             |
+------------------------------------+----------------+----------------+
| > White                            | 83             | 84             |
+------------------------------------+----------------+----------------+
|                                    |                |                |
+------------------------------------+----------------+----------------+
| > Hispanic or Latino               | 76             | 73             |
+------------------------------------+----------------+----------------+
| > Not Hispanic or Latino           | 81             | 79             |
+------------------------------------+----------------+----------------+
| > Black or African American        | 69             | 51             |
+------------------------------------+----------------+----------------+
| > White                            | 83             | 86             |
+------------------------------------+----------------+----------------+
| **Family income level**            |                |                |
+------------------------------------+----------------+----------------+
| > Poor                             | DSU            | DNC            |
+------------------------------------+----------------+----------------+
| > Near poor                        | DSU            | DNC            |
+------------------------------------+----------------+----------------+
| > Middle/high income               | DSU            | DNC            |
+------------------------------------+----------------+----------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

9-9. Increase the proportion of adolescents who have never engaged in
sexual intercourse.

Target and baseline:

+----------+-------------------------------------+---------+----------+
| O        | Increase in Adolescents Aged 15 to  | 1995\   | 2010\    |
| bjective | 17 Years Never Engaging in Sexual   | B       | Target   |
|          | Intercourse                         | aseline |          |
+----------+-------------------------------------+---------+----------+
|          |                                     | #       |          |
|          |                                     | ######  |          |
|          |                                     | Percent |          |
+----------+-------------------------------------+---------+----------+
| *        | Females                             | 62      | 75       |
| *9-9a.** |                                     |         |          |
+----------+-------------------------------------+---------+----------+
| *        | Males                               | 57      | 75       |
| *9-9b.** |                                     |         |          |
+----------+-------------------------------------+---------+----------+

**Target setting method:** Better than the best.

**Data sources:** Females---National Survey of Family Growth (NSFG),
CDC, NCHS; Males---National Survey of Adolescent Males (NSAM), Urban
Institute.

+-------------------------------+------------------+------------------+
| **Adolescents Aged 15 to 17   | **Never Engaged  |                  |
| Years, 1995**                 | in Sexual        |                  |
|                               | Intercourse**    |                  |
+===============================+==================+==================+
|                               | **9-9a.\         | **9-9b.\         |
|                               | Females**        | Males**          |
+-------------------------------+------------------+------------------+
|                               | Percent          |                  |
+-------------------------------+------------------+------------------+
| > **TOTAL**                   | 62               | 57               |
+-------------------------------+------------------+------------------+
| **Race and ethnicity**        |                  |                  |
+-------------------------------+------------------+------------------+
| > American Indian or Alaska   | DSU              | DSU              |
| > Native                      |                  |                  |
+-------------------------------+------------------+------------------+
| > Asian or Pacific Islander   | DSU              | DSU              |
+-------------------------------+------------------+------------------+
| > Asian                       | DSU              | DNC              |
+-------------------------------+------------------+------------------+
| > Native Hawaiian and other\  | DSU              | DNC              |
| > Pacific Islander            |                  |                  |
+-------------------------------+------------------+------------------+
| > Black or African American   | 51               | 24               |
+-------------------------------+------------------+------------------+
| > White                       | 63               | 64               |
+-------------------------------+------------------+------------------+
|                               |                  |                  |
+-------------------------------+------------------+------------------+
| > Hispanic or Latino          | 49               | 50               |
+-------------------------------+------------------+------------------+
| > Not Hispanic or Latino      | 64               | 57               |
+-------------------------------+------------------+------------------+
| > Black or African American   | 52               | 24               |
+-------------------------------+------------------+------------------+
| > White                       | 65               | 65               |
+-------------------------------+------------------+------------------+
| **Family income level**       |                  |                  |
+-------------------------------+------------------+------------------+
| > Poor                        | DSU              | DNC              |
+-------------------------------+------------------+------------------+
| > Near poor                   | DSU              | DNC              |
+-------------------------------+------------------+------------------+
| > Middle/high income          | DSU              | DNC              |
+-------------------------------+------------------+------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Sexual experience, and particularly age at first intercourse, represents
a critical indicator of the risk of pregnancy and STDs. Although all
forms of intercourse (vaginal, oral, and anal) involve risk of disease
transmission, this chapter focuses on avoiding unintended pregnancy and
not on sexual behavior per se. Therefore, the relevant objectives
reference heterosexual, vaginal intercourse only. Youth who begin having
sex at younger ages are exposed to these risks over a longer period of
time. Research has shown that youth who have early sexual experiences
are more likely at later ages to have more sexual partners and more
frequent intercourse.[^37] Adolescents should be encouraged to delay
sexual intercourse until they are physically, cognitively, and
emotionally ready for mature sexual relationships and their
consequences. They should receive education about intimacy; setting
limits; resistance to social, media, peer, and partner pressure; the
benefits of abstinence from intercourse; and prevention of pregnancy and
STDs. Because many adolescents are or will be sexually active, they
should receive support and assistance in developing the skills to
evaluate their readiness for mature sexual relationships. Culturally and
linguistically appropriate materials are needed that can capture the
attention and affect the behaviors of these youth.

9-10. Increase the proportion of sexually active, unmarried adolescents
aged 15 to 17 years who use contraception that both effectively prevents
pregnancy and provides barrier protection against disease.

Target and baseline:

+---------+------------------------------------+-----------+-----------+
| Ob      | Increase in Contraceptive Use at   | 1995\     | 2010\     |
| jective | First\                             | Baseline  | Target    |
|         | Intercourse by Sexually Active,    |           |           |
|         | Unmarried Adolescents Aged 15 to   |           |           |
|         | 17 Years                           |           |           |
+---------+------------------------------------+-----------+-----------+
|         |                                    | ######    |           |
|         |                                    | # Percent |           |
+---------+------------------------------------+-----------+-----------+
|         | **Condom**                         |           |           |
+---------+------------------------------------+-----------+-----------+
| **9     | Females                            | 67        | 75        |
| -10a.** |                                    |           |           |
+---------+------------------------------------+-----------+-----------+
| **9     | Males                              | 72        | 83        |
| -10b.** |                                    |           |           |
+---------+------------------------------------+-----------+-----------+
|         | **Condom plus hormonal method**    |           |           |
+---------+------------------------------------+-----------+-----------+
| **9     | Females                            | 7         | 9         |
| -10c.** |                                    |           |           |
+---------+------------------------------------+-----------+-----------+
| **9     | Males                              | 8         | 11        |
| -10d.** |                                    |           |           |
+---------+------------------------------------+-----------+-----------+

**Target setting method:** Better than the best.

**Data sources:** Females---National Survey of Family Growth (NSFG),
CDC, NCHS; Males---National Survey of Adolescent Males (NSAM), Urban
Institute.

Note: The table below may continue to the following page.

+---------------------------+---------+---------+---------+---+--------+
| **Sexually Active,        | **Used  |         | **Used  |   |        |
| Unmarried Adolescents     | Condom  |         | Condom  |   |        |
| Aged 15 to 17 Years,      | at      |         | Plus    |   |        |
| 1995**                    | First   |         | H       |   |        |
|                           | Interc  |         | ormonal |   |        |
|                           | ourse** |         | Method  |   |        |
|                           |         |         | at      |   |        |
|                           |         |         | First   |   |        |
|                           |         |         | Interc  |   |        |
|                           |         |         | ourse** |   |        |
+===========================+=========+=========+=========+===+========+
|                           | **      | **      | **      | * |        |
|                           | 9-10a.\ | 9-10b.\ | 9-10c.\ | * |        |
|                           | F       | Males** | F       | 9 |        |
|                           | emales\ |         | emales\ | - |        |
|                           | **      |         | **      | 1 |        |
|                           |         |         |         | 0 |        |
|                           |         |         |         | d |        |
|                           |         |         |         | . |        |
|                           |         |         |         | \ |        |
|                           |         |         |         | M |        |
|                           |         |         |         | a |        |
|                           |         |         |         | l |        |
|                           |         |         |         | e |        |
|                           |         |         |         | s |        |
|                           |         |         |         | * |        |
|                           |         |         |         | * |        |
+---------------------------+---------+---------+---------+---+--------+
|                           | Percent |         |         |   |        |
+---------------------------+---------+---------+---------+---+--------+
| > **TOTAL**               | 67      | 72      | 7       | 8 |        |
+---------------------------+---------+---------+---------+---+--------+
| **Race and ethnicity**    |         |         |         |   |        |
+---------------------------+---------+---------+---------+---+--------+
| > American Indian or      | DSU     | DSU     | DSU     | D |        |
| > Alaska Native           |         |         |         | S |        |
|                           |         |         |         | U |        |
+---------------------------+---------+---------+---------+---+--------+
| > Asian or Pacific        | DSU     | DSU     | DSU     | D |        |
| > Islander                |         |         |         | S |        |
|                           |         |         |         | U |        |
+---------------------------+---------+---------+---------+---+--------+
| > Asian                   | DSU     | DNC     | DSU     | D |        |
|                           |         |         |         | N |        |
|                           |         |         |         | C |        |
+---------------------------+---------+---------+---------+---+--------+
| > Native Hawaiian and     | DSU     | DNC     | DSU     | D |        |
| > other Pacific Islander  |         |         |         | N |        |
|                           |         |         |         | C |        |
+---------------------------+---------+---------+---------+---+--------+
| > Black or African        | 60      | 60      | 9       | 1 |        |
| > American                |         |         |         | 2 |        |
+---------------------------+---------+---------+---------+---+--------+
| > White                   | 72      | 77      | 6       | 8 |        |
+---------------------------+---------+---------+---------+---+--------+
|                           |         |         |         |   |        |
+---------------------------+---------+---------+---------+---+--------+
| > Hispanic or Latino      | 52      | 64      | DSU     | 7 |        |
+---------------------------+---------+---------+---------+---+--------+
| > Not Hispanic or Latino  | 71      | 70      | 7       | 7 |        |
+---------------------------+---------+---------+---------+---+--------+
| > Black or African        | 60      | 61      | 9       | 1 |        |
| > American                |         |         |         | 1 |        |
+---------------------------+---------+---------+---------+---+--------+
| > White                   | 75      | 79      | 6       | 8 |        |
+---------------------------+---------+---------+---------+---+--------+
| **Family income level**   |         |         |         |   |        |
+---------------------------+---------+---------+---------+---+--------+
| > Poor                    | DSU     | DNC     | DSU     |   | DNC    |
+---------------------------+---------+---------+---------+---+--------+
| > Near poor               | DSU     | DNC     | DSU     |   | DNC    |
+---------------------------+---------+---------+---------+---+--------+
| > Middle/high income      | DSU     | DNC     | DSU     |   | DNC    |
+---------------------------+---------+---------+---------+---+--------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Target and baseline:

+---------+-----------------------------------+-----------+------------+
| Ob      | Increase in Contraceptive Use at  | 1995\     | 2010\      |
| jective | Last Intercourse by Sexually      | Baseline  | Target     |
|         | Active, Unmarried Adolescents     |           |            |
|         | Aged 15 to 17 Years               |           |            |
+---------+-----------------------------------+-----------+------------+
|         |                                   | #######   |            |
+---------+-----------------------------------+-----------+------------+
|         | **Condom**                        | *Percent* |            |
+---------+-----------------------------------+-----------+------------+
| **9     | Females                           | 39        | 49         |
| -10e.** |                                   |           |            |
+---------+-----------------------------------+-----------+------------+
| **9     | Males                             | 70        | 79         |
| -10f.** |                                   |           |            |
+---------+-----------------------------------+-----------+------------+
|         | **Condom plus hormonal method**   |           |            |
+---------+-----------------------------------+-----------+------------+
| **9     | Females                           | 7         | 11         |
| -10g.** |                                   |           |            |
+---------+-----------------------------------+-----------+------------+
| **9     | Males                             | 16        | 20         |
| -10h.** |                                   |           |            |
+---------+-----------------------------------+-----------+------------+

**Target setting method:** Better than the best.

**Data sources:** Females---National Survey of Family Growth (NSFG),
CDC, NCHS; Males---National Survey of Adolescent Males (NSAM), Urban
Institute.

Note: The table below may continue to the following page.

+-------------------------------+--------+--------+--------+--------+
| **Sexually Active, Unmarried\ | **Used |        | **Used |        |
| Adolescents Aged 15 to 17     | Condom |        | Condom |        |
| Years, 1995**                 | at     |        | Plus   |        |
|                               | Last\  |        | Ho     |        |
|                               | I      |        | rmonal |        |
|                               | nterco |        | Method |        |
|                               | urse** |        | at     |        |
|                               |        |        | Last   |        |
|                               |        |        | I      |        |
|                               |        |        | nterco |        |
|                               |        |        | urse** |        |
+===============================+========+========+========+========+
|                               | **9    | **9    | **9    | **9    |
|                               | -10e.\ | -10f.\ | -10g.\ | -10h.\ |
|                               | Fe     | M      | Fe     | M      |
|                               | males\ | ales** | males\ | ales** |
|                               | **     |        | **     |        |
+-------------------------------+--------+--------+--------+--------+
|                               | P      |        |        |        |
|                               | ercent |        |        |        |
+-------------------------------+--------+--------+--------+--------+
| > **TOTAL**                   | 39     | 70     | 7      | 16     |
+-------------------------------+--------+--------+--------+--------+
| **Race and ethnicity**        |        |        |        |        |
+-------------------------------+--------+--------+--------+--------+
| > American Indian or Alaska   | DSU    | DSU    | DSU    | DSU    |
| > Native                      |        |        |        |        |
+-------------------------------+--------+--------+--------+--------+
| > Asian or Pacific Islander   | DSU    | DSU    | DSU    | DSU    |
+-------------------------------+--------+--------+--------+--------+
| > Asian                       | DSU    | DSU    | DSU    | DSU    |
+-------------------------------+--------+--------+--------+--------+
| > Native Hawaiian and other\  | DSU    | DSU    | DSU    | DSU    |
| > Pacific Islander            |        |        |        |        |
+-------------------------------+--------+--------+--------+--------+
| > Black or African American   | 48     | 78     | 10     | 19     |
+-------------------------------+--------+--------+--------+--------+
| > White                       | 38     | 67     | 6      | 15     |
+-------------------------------+--------+--------+--------+--------+
|                               |        |        |        |        |
+-------------------------------+--------+--------+--------+--------+
| > Hispanic or Latino          | 26     | 59     | DSU    | 10     |
+-------------------------------+--------+--------+--------+--------+
| > Not Hispanic or Latino      | 42     | 65     | 9      | 17     |
+-------------------------------+--------+--------+--------+--------+
| > Black or African American   | 47     | 78     | 10     | 18     |
+-------------------------------+--------+--------+--------+--------+
| > White                       | 40     | 69     | 8      | 16     |
+-------------------------------+--------+--------+--------+--------+
| **Family income level**       |        |        |        |        |
+-------------------------------+--------+--------+--------+--------+
| > Poor                        | DSU    | DNC    | DSU    | DNC    |
+-------------------------------+--------+--------+--------+--------+
| > Near poor                   | DSU    | DNC    | DSU    | DNC    |
+-------------------------------+--------+--------+--------+--------+
| > Middle/high income          | DSU    | DNC    | DSU    | DNC    |
+-------------------------------+--------+--------+--------+--------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

There are two major health consequences of unprotected intercourse among
youth---STDs, including HIV infection, and unintended pregnancy.
Although abstinence is the most effective way for adolescents to avoid
STDs and pregnancy and should be stressed as the certain way to prevent
STDs and pregnancy, sexually active teens must be taught to use condoms
properly, effectively, and consistently. Teenaged females and males who
depend upon hormonal methods of contraception must be educated about the
inability of these methods to prevent STDs. (See Focus Area 13. HIV and
Focus Area 25. Sexually Transmitted Diseases.) Condom use must be
promoted in conjunction with other contraceptive methods.[^38]

Public health messages encourage individuals whose behavior places them
at risk of exposure to STDs, HIV, and unintended pregnancy to use
condoms, as well as effective pregnancy prevention methods, consistently
and correctly.[^39] Sexual intercourse in the teen years, especially
first intercourse, often is unplanned and unprotected by contraception.
Condom use at last intercourse has risen substantially and significantly
among both male and female teenagers, suggesting more protection from
STD transmission. Condom use at first intercourse also has risen---an
important indicator of how well teenagers anticipate and plan for
protection at the initiation of sexual activity. Culturally and
linguistically appropriate materials are needed that can capture the
attention and affect the behaviors of these youth.

While condom use has risen among most teenagers, the use of oral
contraceptives has dropped dramatically, suggesting greater
vulnerability to unintended pregnancy if other hormonal methods or
consistent use of condoms is not practiced. Among currently sexually
active females, the use of oral contraceptives at last intercourse fell
from 43 percent to 25 percent between 1988 and 1995. The reductions in
the use of oral contraception are evident across African American,
Hispanic, and white teenagers. Some of the reduction in oral
contraceptive use is counteracted by the adoption of new hormonal
methods of contraception, such as hormonal implants and injectables. In
1995, 7 percent of sexually active teenaged females overall used these
methods at last intercourse. They were used most widely among sexually
active African American teenaged females: 16 percent reported using
either a hormonal implant or an injectable at last intercourse.[^40]

9-11. Increase the proportion of young adults who have received formal
instruction before turning age 18 years on reproductive health issues,
including all of the following topics: birth control methods, safer sex
to prevent HIV, prevention of sexually transmitted diseases, and
abstinence.

**Target:** 90 percent.

**Baseline:** 64 percent of females aged 18 to 24 years reported having\
received formal instruction on all of these reproductive health issues
before\
turning age 18 years in 1995. (Data on males will be available in the
future.)

**Target setting method:** Better than the best.

**Data source:** National Survey of Family Growth, (NSFG), CDC, NCHS.

Note: The table below may continue to the following page.

+--------------------------------+------------+------------+-----------+
| **Females Aged 18 to 24 Years, | **Received |            |           |
| 1995**                         | Re         |            |           |
|                                | productive |            |           |
|                                | Health\    |            |           |
|                                | I          |            |           |
|                                | nstruction |            |           |
|                                | Prior to   |            |           |
|                                | Age 18     |            |           |
|                                | Years**    |            |           |
+================================+============+============+===========+
|                                | **9-11.\   | **Aged 18  | **Aged 20 |
|                                | Aged 18 to | to 19      | to 24     |
|                                | 24 Years** | Years\***  | Years\*** |
+--------------------------------+------------+------------+-----------+
|                                | Percent    |            |           |
+--------------------------------+------------+------------+-----------+
| > **TOTAL**                    | 64         | 80         | 57        |
+--------------------------------+------------+------------+-----------+
| **Race and ethnicity**         |            |            |           |
+--------------------------------+------------+------------+-----------+
| > American Indian or Alaska    | DSU        | DSU        | DSU       |
| > Native                       |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Asian or Pacific Islander    | DSU        | DSU        | DSU       |
+--------------------------------+------------+------------+-----------+
| > Asian                        | DSU        | DSU        | DSU       |
+--------------------------------+------------+------------+-----------+
| > Native Hawaiian and other\   | DSU        | DSU        | DSU       |
| > Pacific Islander             |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Black or African American    | 65         | 81         | 59        |
+--------------------------------+------------+------------+-----------+
| > White                        | 64         | 81         | 57        |
+--------------------------------+------------+------------+-----------+
|                                |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Hispanic or Latino           | 56         | 69         | 51        |
+--------------------------------+------------+------------+-----------+
| > Not Hispanic or Latino       | 65         | 82         | 58        |
+--------------------------------+------------+------------+-----------+
| > Black or African American    | 66         | 80         | 60        |
+--------------------------------+------------+------------+-----------+
| > White                        | 65         | 83         | 58        |
+--------------------------------+------------+------------+-----------+
| **Family income level**        |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Poor                         | 63         | 82         | 56        |
+--------------------------------+------------+------------+-----------+
| > Near poor                    | 58         | 76         | 52        |
+--------------------------------+------------+------------+-----------+
| > Middle/high income           | 66         | 81         | 60        |
+--------------------------------+------------+------------+-----------+
| ###### Sexual orientation      | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for females aged 18 to 19 years and 20 to 24 years are displayed
to further characterize the issue.

Note: The table above may have continued from the previous page.

All adolescents need education that teaches the interpersonal skills
they will need to withstand pressure to have sex until they are ready
and that includes up-to-date information about methods to prevent
pregnancy and STDs. More important, they need to receive this education
before they start having sex. Ideally, such education would be
developmentally appropriate, include special education students, be
culturally and linguistically appropriate, be medically accurate,
involve parents, and be linked into a broader context of avoiding risky
health behaviors and promoting improved health. Education and knowledge,
however, are not enough. Adolescents need strong reinforcement from
parents, schools, the media, and other sources about the importance of
making conscious, informed, responsible decisions regarding whether to
have intercourse; the necessity of consistent, correct condom use to
protect themselves and their partners against STDs and HIV; and the use
of effective contraception to prevent unintended pregnancy. (See Focus
Area 13. HIV and Focus Area 25. Sexually Transmitted Diseases.)

Becoming a sexually healthy adult is a key developmental task of
adolescence. Adults can encourage adolescent sexual health by providing
accurate information and education about sexuality, fostering
responsible decisionmaking skills, offering support and guidance in
exploring and affirming personal values, and modeling healthy sexual
attitudes and behaviors. Discussions between parents and their children
about sexuality and their family value system related to sexual behavior
are crucial. Yet, many parents of adolescents aged 10 to 15 years in
families today do not talk enough about such important topics as
relationships and becoming sexually active.[^41]

9-12. Reduce the proportion of married couples whose ability\
to conceive or maintain a pregnancy is impaired.

**Target:** 10 percent.

**Baseline:** 13 percent of married couples with wives aged 15 to 44
years had\
impaired ability to conceive or maintain a pregnancy in 1995.

**Target setting method:** 23 percent improvement.

**Data source:** National Survey of Family Growth (NSFG), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Married Couples With Wives Aged 15 to 44     | **Impaired\         |
| Years, 1995**                                  | Fecundity**         |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 13                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 14                  |
+------------------------------------------------+---------------------+
| > White                                        | 13                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 13                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 13                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 14                  |
+------------------------------------------------+---------------------+
| > White                                        | 13                  |
+------------------------------------------------+---------------------+
| **Family income level** (aged 20 to 44 years)  |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 15                  |
+------------------------------------------------+---------------------+
| > Near poor                                    | 13                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 13                  |
+------------------------------------------------+---------------------+
| ###### Select populations                      |                     |
+------------------------------------------------+---------------------+
| ###### Parity status                           |                     |
+------------------------------------------------+---------------------+
| > Parity 0                                     | 25                  |
+------------------------------------------------+---------------------+
| > Parity 1 or more                             | 10                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

A woman is classified as having impaired fecundity if it is impossible
for her (or her husband or cohabiting partner) to have a baby for any
reason other than a sterilizing operation, it is difficult or dangerous
to carry a baby to term, or she and her partner have not used
contraception and have not had a pregnancy for 3 years or longer.
Impaired fecundity includes problems carrying pregnancies to term in
addition to problems conceiving, whereas infertility includes only
problems conceiving. By 1995, there had been a small overall decline in
infertility, which was more marked in Hispanic couples.

Although infertility itself does not represent a serious public health
threat, it carries significant personal, societal, and economic
consequences that call for data surveillance and action. Infertility due
to STDs is a preventable condition. Diagnosis and treatment of
infertility are very costly, time-consuming, and invasive, and they can
place immense stress on marital and family relations. Furthermore, those
costs are likely to rise. The trend to delay childbearing (fecundity
becomes increasingly impaired with age), the availability of fewer
infants for adoption, and the development of new drugs and treatment
procedures will mean that more and more couples seek expensive
infertility services.

9-13. (Developmental) Increase the proportion of health\
insurance policies that cover contraceptive supplies\
and services.

**Potential data source:** The Alan Guttmacher Institute.

In a 1995 report, the Institute of Medicine concluded that among the
reasons for high rates of unintended pregnancy in the United States was
lack of contraceptive coverage by private health insurance.Error:
Reference source not found The report noted that many privately insured
females who need contraceptive care must go out of plan and pay for it
themselves, use over-the-counter methods that may be less effective, or
not use any method at all. It recommended increasing the proportion of
health insurance policies that cover contraceptive services and
supplies.

The issue of private insurance coverage for reversible contraceptive
methods affects most women and their families. Both newer managed care
insurance plans and traditional fee-for-service insurance plans are more
likely to pay for general gynecological services than they are to cover
contraceptive services or supplies.[^42] Many insurance plans do not
cover reversible contraceptive methods. A 1993 survey conducted by the
Alan Guttmacher Institute found that half of indemnity plans and 7
percent of health maintenance organizations (HMOs) do not cover
nonpermanent contraception. The survey also found that plans that do
cover contraceptive services and/or supplies are often inconsistent in
which methods they cover and have a pronounced bias toward covering
permanent surgical methods.[^43]

## Related Objectives From Other Focus Areas

1\. Access to Quality Health Services

1-2. Health insurance coverage for clinical preventive services

1-3. Counseling about health behaviors

1-7. Core competencies in health provider training

3\. Cancer

3-3. Breast cancer deaths

3-4. Cervical cancer deaths

3-10. Provider counseling about cancer prevention

3-11. Pap tests

3-13. Mammograms

7\. Educational and Community-Based Programs

7-2. School health education

7-3. Health-risk behavior information for college and university
students

7-9. Health care organization sponsorship of community health promotion\
activities

7-11. Culturally appropriate and linguistically competent community
health\
promotion programs

11\. Health Communication

11-3. Research and evaluation of communication programs

11-6. Satisfaction with health care providers' communication skills

13\. HIV

13-1. New AIDS cases

13-5. New HIV cases

13-6. Condom use

13-7. Knowledge of serostatus

13-9. HIV/AIDS, STD, and TB education in State prisons

13-10. HIV counseling and testing in State prisons

13-12. Screening for STDs and immunization for hepatitis B

13-14. HIV-infection deaths

13-15. Interval between HIV infection and AIDS diagnosis

13-17. Perinatally acquired HIV infection

14\. Immunization and Infectious Diseases

14-3. Hepatitis B in adults and high-risk groups

14-9. Hepatitis C

14-28. Hepatitis B vaccination among high-risk groups

15\. Injury and Violence Prevention

15-34. Physical assault by intimate partners

15-35. Rape or attempted rape

15-36. Sexual assault other than rape

16\. Maternal, Infant, and Child Health

16-3. Adolescent and young adult deaths

16-4. Maternal deaths

16-5. Maternal illness and complications due to pregnancy

16-6. Prenatal care

16-16. Optimum folic acid levels

16-17. Prenatal substance exposure

19\. Nutrition and Overweight

19-12. Iron deficiency in young children and in females of childbearing
age

19-13. Anemia in low-income pregnant females

19-14. Iron deficiency in pregnant females

25\. Sexually Transmitted Diseases

25-1. Chlamydia

25-2. Gonorrhea

25-3. Primary and secondary syphilis

25-4. Genital herpes

25-5. Human papillomavirus infection

25-6. Pelvic inflammatory disease (PID)

25-7. Fertility problems

25-8. Heterosexually transmitted HIV infection in women

25-9. Congenital syphilis

25-10. Neonatal STDs

25-11. Responsible adolescent sexual behavior

25-12. Responsible sexual behavior messages on television

25-13. Hepatitis B vaccine services in STD clinics

25-14. Screening in youth detention facilities and jails

25-15. Contracts to treat nonplan partners of STD patients

25-16. Annual screening for genital chlamydia

25-17. Screening of pregnant women

25-18. Compliance with recognized STD treatment standards

25-19. Provider referral services for sex partners

26\. Substance Abuse

26-19. Treatment in correctional institutions

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Contraception (birth control):** The means of pregnancy prevention.
Methods include permanent methods (vasectomy for men and tubal ligation
for women) and temporary methods (for example, hormonal implant,
injectable, birth control pill, emergency contraceptive pills,
intrauterine device, diaphragm, female condom, male condom, spermicidal
foam/cream/jelly, sponge, cervical cap, abstinence, natural family
planning, calendar rhythm, and withdrawal).

**Emergency contraceptive pills (ECPs):** The use of prescribed doses of
birth control pills to prevent pregnancy following unprotected vaginal
intercourse. The pills must be taken within 72 hours of having
unprotected sex.

**Family planning:** The process of establishing the preferred number
and spacing of one's children, selecting the means to achieve the goals,
and effectively using that means.

**Federal Title X Family Planning Program:** A program created in 1970
as Title X at the Public Health Service Act. The program provides grants
for the provision of family planning information and services.

**Impaired fecundity:** A broad term used to describe problems with
pregnancy loss as well as problems conceiving a pregnancy.

**Infertility:** Failure to conceive a pregnancy after 12 months of
unprotected intercourse.

**Intended pregnancy:** A pregnancy that a woman states was wanted at
the time of conception.

**Mistimed conception:** Those that were wanted by the woman at some
time in the future but occurred sooner than they were wanted. For
example, a woman became pregnant at age 18 years but actually wanted to
have her first child at age 21 years.

**Parity:** The number of live births a woman has had.

**Unintended pregnancy:** A general term that includes pregnancies a
woman reports as either mistimed or unwanted at the time of conception.
If an unintended pregnancy occurs and is carried to term, the birth may
be a wanted one, but the pregnancy would be classified as unintended.

**Unwanted conception:** Those that occurred when the woman did not want
any pregnancy then or in the future. For example, a woman wanted only
two children but became pregnant with her third.

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