In the 28th and last in the first series
of assessments of Healthy People 2010, Deputy
Assistant Secretary for Health Howard Zucker chaired
a focus area Progress Review on Family Planning, in which
he was assisted by staff of the lead agency for this
Healthy People 2010 focus area, the Office of
Population Affairs (OPA)/U.S. Department of Health and
Human Services (HHS). Dr. Zucker observed that this focus
area embraces the view that every pregnancy should be
planned. The focus area addresses such key issues as
adequate spacing between pregnancies, male involvement
in pregnancy prevention and reproductive health, and
insurance coverage for contraception. Representatives
of the Centers for Medicare and Medicaid Services (CMS),
the Centers for Disease Control and Prevention (CDC),
and other HHS offices and agencies also participated
in the review.
The complete text for the Family Planning focus area
of Healthy People 2010 is accessible at
www.healthypeople.gov/document/html/volume1/09family.htm.
The meeting agenda, tabulated
data for all focus area objectives, charts, and other
materials used in the Progress Review can be found at
www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa09-fp.htm.
Data Trends
Richard Klein of the CDC National Center for Health
Statistics provided an overview of the most significant
recent data bearing on Family Planning. In 2000, an estimated
6.4 million pregnancies in the United States resulted
in 4.1 million live births, 1.3 million induced abortions,
and 1.0 million fetal losses. In 2000, the pregnancy
rate for females age 15 to 44 years was the lowest reported
since 1976. The pregnancy rate among females age 15 to
19 years had declined by 27 percent since 1990. The birth
rate in this age group declined by 30 percent between
1990 and 2003. Nevertheless, the United States still
leads all other developed countries by a wide margin
in teenage birth rates. The estimated overall cost to
the nation of childbearing by adolescent females approaches
$15 billion. Of the 13 objectives in the focus area,
four have shown progress toward the target from the baseline,
two have shown a worsening trend, and two have shown
little or no change. The remaining five cannot be assessed
because data updates were not available to establish
a trend.
Following his overview of the focus area, Mr. Klein
provided details about the five objectives highlighted
in the review. In 2002, 89 percent of females age 15
to 44 years who are at risk of unintended pregnancy used
contraceptives, compared with 93 percent in 1995. In
both of those years, contraceptive use among females
at risk of pregnancy was roughly 10 percent higher among
20- to 44-year-olds than 15- to 19-year-olds. The 2010
target is for 100 percent of females age 15 to 44 years
who are at risk of unintended pregnancy to use contraceptives
(Obj. 9-3). Objective 9-6 aims to increase male involvement
in pregnancy prevention and family planning efforts.
In 2002, the baseline year for this objective, 21 percent
of sexually experienced, unmarried males age 15 to 24
years reported that they had accompanied a female partner
to a family planning clinic at least once. In that year,
the proportion of such males who had visited a clinic
broke down by age cohort as follows: 24 percent of those
age 22 to 24 years, 25 percent of those age 20 to 21
years, 21 percent of those age 18 to 19 years, and 13
percent of those age 15 to 17 years.
In 2000, the pregnancy rate among female adolescents
age 15 to 17 years was 54 per 1,000, compared to 67 per
1,000 in 1996. The pregnancy rates in 2000 for the three
largest racial/ethnic groups were as follows: non-Hispanic
blacks—101 per 1,000; Hispanics—83 per 1,000;
and non-Hispanic whites—33 per 1,000. The target
is 43 per 1,000 (Obj. 9-7). In 2002, 70 percent of adolescent
females age 15 to 17 years had never engaged in sexual
intercourse, compared with 62 percent in 1995. Among
males in that age group, 68 percent had always been abstinent
in 2002, compared with 62 percent in 1995. Abstinence
rates over that time span increased for both genders
of three racial/ethnic groups in the age cohort for whom
data were available: from 52 percent to 59 percent among
non-Hispanic black females; from 65 percent to 70 percent
among non-Hispanic white females; from 49 percent to
75 percent among Hispanic females; from 24 percent to
47 percent among non-Hispanic black males; from 65 percent
to 75 percent among non-Hispanic white males; and from
50 percent to 57 percent among Hispanic males. The target
is 75 percent (Obj. 9-9). Among unmarried females age
15 to 17 years, condom use by the partner at last intercourse
increased from 39 percent in 1995 to 56 percent in 2002,
thus surpassing the target of 49 percent (Obj. 9-10e).
Among unmarried males in that age cohort, condom use
at last intercourse increased from 70 percent to 84 percent
over that time span, surpassing the target of 79 percent
(Obj. 9-10f).
Key Challenges and Current Strategies
The principal themes of the presentations that followed
the data overview were introduced by Alma Golden, Deputy
Assistant Secretary for Population Affairs and Director
of OPA. Dr. Golden was followed by Dennis Smith, Director
of the CMS Center for Medicaid and State Operations,
and by John Douglas, Jr., Director of the Division of
STD Prevention of CDC’s National Center for HIV,
STD, and TB Prevention. These agency representatives
led discussions with review participants, who identified
a number of barriers to achieving the objectives and
activities under way to meet these challenges, including
the following:
According to data from the National Survey of Family
Growth (NSFG), in the United States, approximately half
of all pregnancies across the age spectrum are “unintended”
and may be associated with social, economic, and medical
costs. Dr. Golden noted that, although a pregnancy may
be reported as unintended, most children at birth are
welcomed and nurtured. The social costs of unintended
births can include reduced educational attainment and
employment opportunity, greater dependence on welfare,
and increased potential for child abuse and neglect,
with greater impact noted for adolescent mothers. In
general, women who lack preparedness for pregnancy are
less likely to receive timely prenatal care, and their
infants are more likely to lack sufficient resources
for healthy development. -
Chlamydia and gonorrhea, the two most common sexually
transmitted diseases (STDs), can have serious reproductive
health consequences for women. Both infections can
be asymptomatic in a large proportion of infected
women. If left untreated, an estimated 20 to 50 percent
of chlamydia cases and an estimated 10 to 40 percent
of gonorrhea cases will lead to pelvic inflammatory
disease, a frequent cause of infertility, ectopic
pregnancy, and chronic pelvic pain. Persons under
age 25 years account for 74 percent of chlamydia
and 60 percent of gonorrhea infections. [Please refer
to the July 21, 2004, Progress Review on STDs, which
is accessible at www.healthypeople.gov/data/2010prog/focus25.]
The Title X Family Planning Program, administered
by OPA, is the only Federal program devoted solely to
the provision of family planning and reproductive health
care. The program supports a nationwide network of approximately
4,600 clinics and serves approximately 5 million persons
annually. Almost two-thirds of Title X clients have incomes
at or below the Federal Poverty Level. OPA also administers
the Title XX Adolescent Family Life Program, which includes
prevention programs emphasizing abstinence and activities
providing health care and educational and social services
to pregnant and parenting teenagers. Under the Medicaid program, states are required
to provide family planning services and supplies for
categorically eligible Medicaid beneficiaries, for which
the Federal reimbursement rate is 90 percent. Twenty-one
states now have Medicaid demonstration waivers that expand
eligibility for family planning services. For example,
some demonstrations, which must be “budget neutral,”
provide postpartum women with an additional 1 or 2 years
of coverage for family planning services beyond the regular
Medicaid limit. Other demonstrations have extended Medicaid
coverage for family planning to residents not previously
covered under the program by expanding the income eligibility
requirements. The mainstay of the Federal response to the chlamydia
epidemic is the National Infertility Prevention Program,
a collaboration between OPA and CDC that has been in
existence for 16 years. A pilot program, begun in HHS
Region X in 1988, produced a 50 percent decrease in chlamydia
prevalence (positivity) rates in family planning clinics
over 3 years. That success sparked national legislation
to respond actively to preventable causes of infertility
and led to expansion of the program into all 10 HHS Regions.
Almost $30 million has been awarded to 65 grantees in
the Regions. Several other Federal programs, including the
CDC Division of School and Adolescent Health and the
Health Resources and Services Administration’s
Special Projects of Regional and National Significance
(SPRANS), also contribute to efforts to prevent adolescent
pregnancy and improve reproductive health.
Approaches for Consideration
Participants in the review made the following suggestions
for steps that health professionals and policymakers
could take to enable further progress toward achievement
of the objectives for the Family Planning focus area:
In counseling teenagers and adults, health
professionals and other counselors should place greater
emphasis on the concept of all-around preparedness for
pregnancy, including assessment of physical health, social
and economic support systems, and family/marriage stability
as component contributors to healthy childbearing and
child rearing. This approach has the advantage of integrating
efforts to prevent and control HIV/STDs and of increasing
involvement of male partners. Ensure that future family planning research will
include strong components centered on improvement of
providers' delivery of services, pregnancy planning for
families, and involvement of parents in adolescent education. Support the expansion and wider availability
to youth of athletic programs and other supervised after-school
activities, which have been shown to delay the onset
of sexual behaviors. Ensure that staff of family planning clinics
are provided training on how to address with youth the
exploitative and coercive behavior of older individuals
in sexual partnerships with minors. Expand screening and counseling for chlamydia
and gonorrhea to additional public health and primary
care settings. Enhance efforts to expand outreach by staff of
family planning clinics to provide services for special
populations, including tribal units, individuals with
disabilities, incarcerated populations, and vulnerable
populations. Devise measures for determining the degree of
intent and preparation that couples consider before the
female partner becomes pregnant. These measures should
take account of the influence interventions such as education
and healthcare services have on outcomes. Expand research on ways to counter the deleterious
effects on young people of media presentations that glorify
physical abuse and sexual exploitation.
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Contacts for information about Healthy People
2010 focus area 9—Family Planning:
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Cristina V. Beato, M.D.
Acting Assistant Secretary for Health
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