9. Contraception, Abortion, and Population Planning

PATRICIA BARTHALOW KOCH

A. Contraception

PATRICIA BARTHALOW KOCH

“The struggle for reproductive self-determination is one of the oldest projects of humanity; one of our earliest collective attempts to alter the biological limits of our existence” (Gordon 1976, 403). Throughout U.S. history, as elsewhere, many have been desperate to learn safe and effective ways to prevent conception and induce abortion, while others have believed artificial contraception is unacceptable because it interferes with the course of nature.

Brodie (1994) conducted a historical analysis of efforts for reproductive control in colonial and nineteenth-century America. New England fertility rates in colonial times were higher than those in most of Europe. Colonists had little real ability, and perhaps little will, to intervene in their reproduction. It has been estimated that one third of the brides of this time were pregnant. Although the Puritans viewed marriage with children as the highest form of life, the prevalence of premarital pregnancy was not viewed as a threat to this value, because virtually all such pregnancies led to marriage (Reiss 1980).

On the other hand, Native Americans seemed to possess knowledge and cultural practices - breast-feeding, periodic abstinence, abortion, and infanticide - specific to their particular tribes, enabling them to maintain small families. Fertility among the African and Caribbean women brought as slaves varied widely, depending on the region of the United States - in some places, fecundity reaching human capacity and in other places, fertility rates decreasing. According to Brodie (1994, 53): “Fecundity assured slave women that they were valuable to the master and offered some hope against being sold. Yet preventing the birth of new slaves for the master could be a form of resistance to slavery.”

The three most common forms of birth control during this time were coitus interruptus (withdrawal), breast-feeding, and abortion. The effectiveness of breast-feeding in preventing another pregnancy depended on how long the woman breast-fed, on when her menstruation resumed after childbirth, and on how long and how often the infant suckled. However, by the nineteenth century, the option of bottle feeding infants was becoming more available and popular.

Abortion methods included violent exercises, uterine insertions, and the use of drugs. These methods may have been no more dangerous than the pregnancy and childbirth complications of the time, but it has been suggested that these methods were also a common cause of death for women. American folk medicine was evolving from the knowledge and indigenous practices of the Native Americans, European settlers, and African/Caribbean slaves. Many abortificients were made from plants, such as pennyroyal, tansy, aloe, cohash, and squaw root. Such “remedies” were often passed down through family Bibles and cookbooks. Over 1,500 medical almanacs, many containing herbal remedies to “bring on a woman's courses,” were circulated before the American Revolution. Yet there was little public discussion of birth control and no laws or statutes governing information or practice.

Brodie documents that reproductive control during most of the nineteenth century in America was neither rare nor taboo. Information was available about withdrawal, douching (the “water cure”), rhythm (although the information was not very accurate), condoms, spermicides, abortion-inducing drugs, and early varieties of the diaphragm. When other contraceptive options were available, couples seemed to prefer them over withdrawal; sexual abstinence was not one of the chief means of controlling birth rates. Abortion was not illegal until “quickening” (movement of the fetus).

Beginning in the 1830s, reproductive control became a commercial enterprise in the expanding American market economy. Douches and syringes, vaginal sponges, condoms, diaphragms (or “womb veils”), cervical caps, and pessaries (intravaginal and intrauterine devices) began to be widely advertised through a burgeoning literature on the subjects of sexuality and reproductive control, euphemistically called “feminine hygiene.” Education through this means was made possible by the technological improvements in printing and the increased basic literacy of the American public.

The self-help literature instructed readers on how to make contraceptive and abortion agents at home from products readily available in the household or garden. Douching was the most frequent method for reproductive control used by middle- and upper-class women. The invention of the vulcanization process for rubber by Goodyear in the 1840s enabled condoms to be made more cheaply. In addition, the appearance of the mail-order catalog allowed the public to “shop” for contraceptive devices confidentially.

The birthrate of white native-born married women was reduced almost by half between 1800 and 1900, coinciding with the major social upheaval of industrialization and urbanization. Many American couples wanted fewer children and greater spacing between them. This became possible with the evolving availability of information about and access to more-effective contraceptive techniques.

By the mid-1800s, the abortion rate among the white middle class increased sharply with greater access to diverse sources of information about abortion, abortion drugs and instruments, and persons offering abortion services. There was little outcry about abortion being “immoral” until the American Medical Association launched a campaign to curb it at mid century. Historians have debated whether the new opposition to abortion by male physicians was due more to the threat of competition from female midwives or to a concern about the dangers of unsafe abortion.

As reproductive control became commercialized after 1850, and as some women became increasingly able to assert a degree of independent control over their fertility through contraception and abortion, the deep ambivalences with which many Americans regarded such changes came increasingly into play. In the second half of the nineteenth century, diverse groups emerged to try to restore

American “social purity,” and one of the issues they focused on was restricting sexual freedom and control of reproduction.... All branches of government were their allies; their goals were won through enactments of federal and state legislation and sustained by judicial decisions that criminalized contraception and abortion, both of which had in earlier decades been legal. (Brodie 1994, 253)

The combined force of the social purity legions and of overwhelming public acquiescence overrode a generation of commercialization and growing public discourse and drove reproductive control, if not totally back underground, at least into a netherworld of back-fence gossip and back-alley abortion. (Brodie 1994, 288)

What is referred to as “the birth-control movement” was begun in the United States shortly before World War I, primarily by socialists and sexual liberals as both a political and moral issue. Margaret Sanger's leadership, in the early 1900s, was responsible for gaining support from mainstream America and centralizing the cause through her American Birth Control League. Sanger attributed her indomitable dedication to making birth-control information and methods available to American women, particularly of the working class, to her nursing experiences with poor women during which they would beg her to tell them the “secrets” of the rich for limiting children.

In 1915, she began publishing Woman Rebel, a monthly magazine advocating birth control. She was indicted for violating the Comstock Law, but the case was dropped and she continued dispensing birth-control information through lectures and publications. In 1916, she was arrested again for opening the first birth-control clinic in the United States in a poor slum in Brooklyn, New York. She served thirty days in jail; however, the testimonials of her poor birth-control clients at the trial helped to fuel the birth-control movement.

Gordon (1976) documents the birth-control movement throughout the twentieth century in the United States. In the early 1920s, most doctors were opposed to contraception. However, through the efforts of Margaret Sanger and Dr. Robert Latou Dickenson, contraception was scientifically studied and became accepted as a health issue, not simply a moral one. Clergy, particularly of the Protestant and Jewish faiths, also began to view contraceptive choice as an individual moral decision when it affected the health of a family. To this day, however, the Catholic Church has remained staunch in its opposition to “artificial birth control.” Yet, this opposition has not deterred Catholic women in the United States from using birth-control methods as frequently as women of other or no faiths.

The Great Depression of the 1930s forced many more Americans into accepting and practicing birth-control measures. Social workers, based on their interactions with many poor and struggling families, became proponents in support of better education about, and access to, birth control for all women, not just the middle class and wealthy. The manufacturing of condoms became a large industry. In the 1930s, with the formation of the American Birth Control League, over three hundred clinics throughout the United States were providing contraceptive information and services; this increased to more than eight hundred clinics by 1942.

Yet, despite the fact that a 1937 poll indicated that 79 percent of American women supported the use of birth control, those who did not have access to private doctors were limited in their access to birth-control information and devices. However, judges, doctors, government officials, entrepreneurs, and others were beginning to respond to grassroots pressure. For example, in 1927, the American Medical Association officially recognized birth control as part of medical practice. In 1942, Planned Parenthood Federation of America (PPFA) was founded with a commitment to helping women better plan family size and child spacing. PPFA was greatly responsible for making birth control more accessible to women of various backgrounds, particularly those of lower-socioeconomic levels, throughout the United States.

Development of the Oral Contraceptive Pill and IUD

During the 1950s, research was progressing in the United States that would transform contraceptive technology and practice worldwide. Asbell (1995) details the biography of the “drug that changed the world.” The quest for a female contraceptive that could be “swallowed like an aspirin” began when Margaret Sanger and Katherine McCormick, a wealthy American woman dedicated to the birth-control movement, enlisted Gregory Pincus, an accomplished reproductive scientist, to develop a contraceptive pill. Applying the basic research findings of others, particularly Russel Marker, who produced a chemical imitation of progesterone from the roots of Mexican yam trees, Pincus developed just such a pill combining synthetic estrogen and progesterone.

With the help of John Rock, a noted Harvard gynecologist and researcher, the oral contraceptive was initially given to fifty Massachusetts volunteers, and then field tested with approximately 200 women in Puerto Rico in 1956, where it was believed opposition to such a drug would be less than in the United States. However, the pill was heartily condemned by the Catholic Church, leaving Puerto Rican women to face the dilemma of choosing to be in the trials (and committing a mortal sin) or bearing more children which they could not adequately support. In addition, the standards for informed consent for research subjects were not as strict as they are today, so that participants in these trials were not thoroughly informed as to the experimental procedures being used and the potential risks involved (which were generally unknown).

In 1957, the pill was first approved by the Food and Drug Administration (FDA) for treatment of menstrual disorders. At this time, it was observed that many women who had never before experienced menstrual disorders suddenly developed this problem and sought treatment with the pill. By 1960, the pill was formally approved by the FDA as a contraceptive following double-blind clinical trials with 897 Puerto Rican women. Such a procedure would well be considered ethically questionable today.

The pill was extremely attractive to many potential users because of its convenience and efficacy. Women now had the option of engaging in intercourse with minimal threat of pregnancy. This method separated the act of coitus from the action taken to restrict fertility (ingestion of the pill). In addition, the woman was in sole charge of this method of birth control and did not need any cooperation from her male partner. Many believed this innovation in birth control was responsible for a “sexual revolution” in which women were to become more “sexually active,” displaying patterns of sexual attitudes and behaviors more like men, although there is little scientific evidence to support this claim. As Ira Reiss explained the evolutionary changes taking place in American sexual expression:

Sexual standards and behavior seem more closely related to social structure and cultural and religious values than to the availability of contraceptive techniques... [increased premarital sexuality] was promoted by a courtship system that had been evolving for a hundred years in the United States permitting young people to choose their own marriage partners, and which therefore encouraged choice of when as well as with whom to share sex. (Asbell 1995, 201)

Twenty-five years later, oral contraception has become one of the most extensively studied medications ever prescribed. Today, pills with less than 50 micrograms of estrogen are associated with a significantly lower risk of serious negative effects and are as effective in preventing pregnancy as the higher-dose pills of the past (Hatcher et al. 1994).

The intrauterine device (IUD) also became popular in the United States as the “perfect” alternative to the pill because of its effectiveness and convenience. However, the Dalkon Shield, which was marketed from 1971 to 1975, was implicated in a number of cases of pelvic inflammatory disease and spontaneous septic abortions resulting in the deaths of at least twenty women. In 1974, the Shield was taken off the U.S. market, although it was still distributed abroad. Currently, there are only two IUDs for sale in the United States, the TCu-380A (ParaGard) and the Progesterone T device (Progestasert).

Government Policy and Legal Issues

While research was expanding birth-control options, the 1950s and 1960s saw the development and implementation of federal policies supporting population control programs designed to deal with overpopulation throughout the world. Birth control was offered as a “tool” for economic development to Third World countries. The 1960 budget of $2 million for family-planning programs grew to $250 million in 1972 (Asbell 1995). However, American goals were often in conflict with the cultural beliefs of the people in various countries. Reproductive options cannot be separated from the economic options and social mores of a culture.

Governmental policies on birth control were also changing at home. In 1964, President Lyndon B. Johnson, over strong political opposition, provided federal funds to support birth-control clinics for the American poor. These efforts were continued by President Richard M. Nixon, who in 1970 declared “a new national goal: adequate family-planning services within the next five years for all those who want them but cannot afford them” (Asbell 1995).

Important legal changes were also occurring in the U.S. during this time. In 1965, the Supreme Court decided, in Griswold v. Connecticut, that laws prohibiting the sale of contraceptives to married couples violated a constitutional “right of privacy.” Writing the majority opinion, Justice William O. Douglas declared:

we deal with a right of privacy older than the Bill of Rights - older than our political parties, older than our school system. Marriage is a coming together for better or worse, hopefully enduring and intimate to the degree of being sacred. (Asbell 1995, 241)

In 1972, the Supreme Court extended this “right to privacy” for contraceptive use to unmarried people (Eisenstadt v. Baird) on the basis that a legal prohibition would violate the equal protection clause of the 14th Amendment. A 1977 Supreme Court decision (Carey v. Population Services) struck down laws prohibiting the sale of contraception to minors, the selling of contraception by others besides pharmacists, and advertisements for or displays of contraceptives.

Recent Developments in Birth Control

More-recent developments in contraceptive technology receive tougher scrutiny than in the past before winning FDA approval. For example, Norplant was developed by the international nonprofit Population Council, which began clinical trials including half a million women in 46 countries, not including the U.S.

However, Norplant was not approved for use in the United States by the Food and Drug Administration (FDA) until 1990. This approval was opposed by the National Women's Health Network because the long-term safety of Norplant had not been established. Wyeth-Ayerst, the U.S. distributor, is required by law to report any unusual events associated with Norplant use to the FDA, while an internationally coordinated surveillance of Norplant use and its effects is being conducted by the World Health Organization and others in eight developing countries. Currently, a class-action suit is being formulated by a group of Norplant users in the U.S., primarily because of the difficulties they experienced in having the Norplant rods removed. Such complications are a serious impediment keeping American pharmaceutical companies from researching and developing new contraceptives.

Depro-Provera (Depo-medroxyprogesterone acetate or DMPA) is the most commonly employed injectable progestin used in over ninety countries worldwide. However, it was not approved for use in the U.S. by the FDA until 1992. Women's health activists, organized by the National Women's Health Network, had opposed its approval in the absence of more long-term studies of its safety.

In 1993, the FDA approved the first female condom, called Reality, for over-the-counter sale in the United States. The female condom, or vaginal pouch, is a polyurethane lubricated sheath that lines the vagina and partially covers the perineum. Although the method failure rate of the female condom (5 percent) is similar to that of the male condom (3 percent), it has a higher failure rate with typical use (21 percent) than does the male condom (12 percent) (Hatcher et al. 1994). This may reflect the “newness” of this female method and inexperience with its use. Yet, in a study of 360 women using female condoms, only 2 discontinued its use.

Although a combination of RU-486 (mifespristone) and prostaglandin has been tested in over a dozen countries, particularly in France, it has generated controversy in the U.S. and was only approved for use here in 1996. Because RU-486, when combined with a prostaglandin, is an effective early abortifacient, its use has been opposed by anti-abortion proponents, even for research purposes or its potential use in the treatment of breast cancer, Cushing's syndrome, endometriosis, and brain tumors. Because it was so politically controversial, RU-486 had not been expected to be approved for any use in the United States, which turned out not to be the case.

What is the future for the development of new birth-control methods in the United States? Contraceptive-vaccine researchers acknowledge that a new form of birth control for men is badly needed. Yet, it is believed that immunizing men against their own sperm would risk destroying the testes. However, researchers in the U.S. are talking with the FDA to test a vaccine with women that induces the woman's immune system to attack sperm. Previously, such vaccines have been tested on mice, rabbits, and baboons with an effectiveness rate of 75 to 80 percent.

In the past, Federal agencies have shied away from supporting such work because “right-to-lifer” advocates view such a vaccine as abortive and, therefore, unacceptable. In addition to the possibility of medical liability, American pharmaceutical companies are unlikely to market such a vaccine because of the protests and boycotts that “right-to-life” groups threaten to organize. Because of the threat of boycotts from adversarial groups and lawsuits from persons claiming to be harmed by new contraceptive technologies, only one American company remains active in contraceptive research and development. In the late 1960s, nine American drug companies were competing to find new and better birth-control methods.

Current Contraceptive Behavior

Between 1988 and 1990, the proportion of women in the United States, from the age of 15 to 44, who had never had vaginal-penile intercourse declined from 12 percent to 9 percent. (Data used in this section are based on the 1982 and 1988 National Survey of Family Growth (NSFG) and the 1990 NSFG Telephone Reinterview) (Peterson 1995). The proportion of 15- to 44-year-olds who were at risk for unintended pregnancy but were not contracepting increased from 7 percent to 12 percent. This increase was most pronounced among 15- to 44-year-olds (8 percent to 22 percent), never-married women (11 percent to 20 percent), and non-Hispanic white women (5 percent to 11 percent).

In 1990, 34.5 million women, or 59 percent of those aged 15 to 44, in the United States were using some type of contraception - with almost three quarters (70.7 percent) of married women using contraception; see Table 6. There is little difference in contraceptive use based on religious background between Catholic, Protestant, and Jewish women. The leading methods used by contraceptors were female sterilization (29.5 percent), the contraceptive pill (28.5 percent), and the male condom (17.7 percent). (Information on the use of three newer methods - Norplant, the female condom, and Depo-Provera - was not available at the time of the surveys). Overall, the use of female and male sterilization, the condom, and periodic abstinence had increased from 1988, whereas the use of the pill, IUD, and diaphragm had decreased.

Female sterilization is most widely used among older and less-educated women who have completed their childbearing, with over one half (52.0 percent) of female contraceptors age 40 to 44 having been sterilized. Anglo-American women are much more likely to have male partners with a vasectomy (15.5 percent) than are African-American women (1.3 percent). The aging of the baby-boom generation in the United States portends a continued rise in female sterilization rates throughout the next decade and a rise in vasectomies among the better educated.

The increased use of the condom was most pronounced among young (aged 15 to 44), African-American, never-married, childless, or less-educated women, and those living below the poverty level. For example, condom use among never-married women tripled between 1982 and 1990 (4 percent to 13 percent). The percentage of adolescents using condoms rose from 33 percent to 44 percent between 1988 and 1990. Almost all contracepting teenagers used either the pill (52 percent) or condom (44 percent) in 1990. However, it must be kept in mind that only 56 percent of condom users report using them consistently every time they have intercourse.

The use of contraception at first intercourse by adolescents has increased significantly since the early 1980s. For example, during 1980-1982, 53 percent of unmarried women aged 15 to 19 used contraception during their first intercourse experience. By 1988-1990, this percentage rose to 71 percent, mainly attributable to rising condom use (from 28 percent to 55 percent). The increase in condom use was particularly striking among Hispanic teens, with a threefold increase from 1980 to 1990 (17 percent to 58 percent).

Table 6: Number of Women 15-44 Years of Age, Percent Using Any Method of Contraception, and Percent Distribution of Contraceptors by Method, According to Age, Race and Origin, and Marital Status, 1988 and 1990

Age, Race, and Marital Status		Number of Women Using a Method (in Thousands)	Percent Using Any Method	Female Sterilization	Male Sterilization	Pill	IUD	Diaphragm	Condom	Periodic Abstinence1	Other
19902
All women		34,516	59.3	29.5	12.6	28.5	1.4	2.8	17.7	2.7	4.8
Age
15-19		2,623	31.5	0.0	0.0	52.0	0.0	0.0	44.0	1.0	3.0
	15-17	1,165	24.3	0.0	0.0	41.1	0.0	0.0	51.9	2.2	4.7
	18-19	1,458	41.2	0.0	0.0	60.7	0.0	0.0	37.6	0.0	1.7
20-24		5,065	55.3	8.0	1.8	55.4	0.8	0.6	25.3	2.8	5.3
25-29		6,385	60.0	17.4	5.0	47.3	0.4	2.3	19.0	2.7	5.9
30-34		7,344	66.2	32.7	13.0	23.9	0.9	4.7	15.9	3.5	5.4
35-39		7,138	70.6	44.2	19.8	10.6	3.3	3.3	10.3	3.4	5.2
40-44		5,962	66.9	52.0	26.5	2.2	1.8	3.8	9.2	1.6	2.9
Race and Origin
Hispanic		2,856	52.2	33.1	6.4	31.4	1.9	1.5	17.1	3.7	5.1
White non-Hispanic		25,928	60.5	27.3	15.5	28.5	1.3	3.0	17.0	2.7	4.7
Black non-Hispanic		4,412	58.7	41.0	1.3	28.5	1.4	1.6	19.4	1.2	5.6
Marital Status
Currently married		21,608	70.7	33.5	33.5	19.2	20.6	1.4	14.0	3.5	3.8
Divorced, separated, widowed		4,026	57.3	52.1	2.8	22.4	2.5	0.9	9.7	0.6	9.0
Never married		8,882	43.0	9.6	1.1	50.5	0.8	0.6	30.1	1.8	5.5
1988
All women		34,912	60.3	27.5	11.7	30.7	2.0	5.7	14.6	2.3	5.4
Age
15-19		2,950	32.1	1.5	0.2	58.8	0.0	1.0	32.8	0.8	4.8
	15-17	1,076	19.9	0.0	0.0	53.3	0.0	0.7	40.4	0.9	4.7
	18-19	1,874	49.6	2.4	0.4	61.9	0.0	1.2	28.4	0.8	4.9
20-24		5,550	59.0	4.6	1.8	68.2	0.3	3.7	14.5	1.7	5.2
25-29		6,967	64.5	17.0	6.0	44.5	1.3	5.5	15.6	2.4	7.6
30-34		7,437	68.0	32.5	14.0	21.5	2.9	8.9	12.0	2.7	5.5
35-39		6,726	70.2	44.9	19.7	5.2	2.7	7.7	11.8	3.0	5.1
40-44		5,282	66.0	51.1	22.2	3.2	3.7	3.9	10.5	2.2	3.2
Race and Origin
Hispanic		2,799	50.4	31.7	4.3	33.4	5.0	2.4	13.6	2.5	7.1
White non-Hispanic		25,799	62.9	25.6	14.3	29.5	1.5	6.6	15.2	2.3	5.0
Black non-Hispanic		4,208	56.8	37.8	0.9	38.1	3.2	2.0	10.1	2.1	5.9
Marital Status
Currently married		21,657	74.3	31.4	17.3	20.4	2.0	6.2	14.3	2.8	5.6
Divorced, separated, widowed		4,429	57.6	50.7	3.6	25.3	3.6	5.3	5.9	1.9	3.8
Never married		8,826	41.9	6.4	1.8	59.0	1.3	4.9	19.6	1.3	5.7

¹ Includes natural family planning and other types of periodic abstinence.

² Percentages for 1990 were calculated excluding cases for whom contraceptive status was not ascertained. Overall, contraceptive status was not ascertained for 0.3 percent of U.S. women in 1990.

Source: Peterson, L. S. (1995, February). “Contraceptive Use in the United States: 1982-1990.” From Vital and Health Statistics. Advanced Data No. 260, Hyattsville, MD: National Center for Health Statistics.

B. Childbirth and Single Women

Each year, one million American teenage girls become pregnant, a per-thousand rate twice that of Canada, England, and Sweden, and ten times that of the Netherlands. A similar disproportionately high rate is reported for teenage abortions (Jones et al. 1986).

The birthrate for unmarried American women has surged since 1980, with the rate for white women nearly doubling, and the rate for teenagers dropping from 53 percent of the unwed births in 1973, to 41 percent in 1980, and 30 percent in 1992. One out of every four American babies in 1992 was born to an unmarried woman. The unwed birthrate rose sharply for women 20 years and older. The highest rates were among women ages 20 to 24 (68.5 births per 1,000), followed by 18- and 19-year olds (67.3 per 1,000) and 25- to 29-year-olds (56.5 per 1,000). Overall, according to a 1995 report from the National Center for Health Statistics, the unmarried birthrate rose 54 percent between 1980 and 1992, from 29.4 births per 1,000 unmarried women ages 15 to 44 in 1980 to 45.2 births per 1,000 in both 1991 and 1992 (Holmes 1996a).

In 1970, the birthrate for unmarried black women was seven times the rate for white women, and four times the rate for white women in 1980. Since 1980, the white unmarried birthrate has risen by 94 percent while the rate for blacks rose only 7 percent. By 1992, the birthrate for single black women was just 2.5 times the rate for white women. In 1992, the out-of-wedlock birthrates were 95.3 for Hispanic women, 86.5 for black women, and 35.2 for white women (Holmes 1996a).

Commenting on the social implications of these statistics, Charles F. Westoff, a Princeton University demographer, said they “reflect the declining significance of marriage as a social obligation or a social necessity for reproduction.” Poorly educated, low-income teenage mothers and their children are overwhelmingly likely to experience long-term negative consequences of early childbearing as single parent (Associated Press News Release, June 7, 1995). A 1996 study, sponsored by the charitable Robin Hood Foundation, estimated the public cost of unwed teenage pregnancy at $7 billion. The study looked at the consequences for teenage mothers, their children, and the fathers of the babies, compared with people from the same social background when pregnancy was delayed until the woman was 20 or 21. The breakdown of annual costs included $2.2 billion in welfare and food-stamp benefits, $1.5 billion in medical-care costs, $900 million in increased foster-care expenses, $1 billion for additional prison construction, and $1.3 in lost tax revenue from the reduced productivity of teenage women who bear children (Holmes 1996a).

Table 7: Percentage of Women Experiencing a Birth Control Failure During the First Year of Typical Use and the First Year of Perfect Use and the Percentage Continuing Use at the End of the First Year

Method		% of Women Experiencing an Accidental Pregnancy Within the First Year of Use		% of Women Continuing Use at One Year
		Typical Use	Perfect Use
Chance		85	85
Spermicide		21	6	43
Periodic Abstinence		20		67
	Calendar		9
	Ovulation Method		3
	Sympto-Thermal		2
	Post-Ovulation		1
Withdrawal		19	4
Cap (with spermicide)
	Parous Women	36	24	45
	Nulliparous Women	18	9	58
Sponge
	Parous Women	36	20	45
	Nulliparous Women	18	9	58
Diaphragm (with spermicide)		18	6	58
Condom
	Female (Reality)	21	5	56
	Male	12	3	63
Pill		3
	Progestin Only		0.5	N.A.
	Combined		0.1	N.A.
IUD
	Progesterone T	2.0	1.5	81
	Copper T 380A	0.8	0.6	78
Depo-Provera		0.3	0.3	70
Norplant (6 Capsules)		0.09	0.09	85
Female Sterilization		0.4	0.4	100
Male Sterilization		0.15	0.10	100

Source: Hatcher, R. et al. (1994). Contraceptive Technology (16th rev. ed.) p. 13. New York: Irvington.

In any given year, roughly 12 percent of American infants are born to teenage mothers. However, the vast majority of these teenage mothers are 18 or 19 years old, and thus only technically teenagers. American teenagers have been producing children at about the same rate for most of this century. Fewer than a third of all single mothers are teenagers, even when we include the 18- to 19-year-olds. And this proportion is declining. What is different in recent decades is that increasing numbers of teenage mothers are unmarried when they give birth. In 1970, only 30 percent of teenage mothers had never been married; by 1995, 70 percent of teenage mothers had never been married (Luker 1996).

While there is no good reason to suppose that the teenage birthrate is going up in any significant way - it was, in fact, higher in the 1950s - one must admit that the rate of single parenting is going up. In 1947, virtually all single mothers were widows, or living apart from their mate after separation or divorce. In 1947, fewer than one in a hundred had never been married. Today, overall, never-married single mothers account for one in three, and the percentage is rising. The number of single teenage mothers is going up at a rapid rate, but so is the number of single mothers at every age.

These data suggest that we are participants in, or at least witness to, an important shift in the nature of American family life that is echoing throughout the industrialized world. According to Luker (1996), the last years of this century may turn out to be the beginning of a time when the very notions of childrearing on the one hand and family life on the other are increasingly disconnected. While the rate of out-of-wedlock births is clearly on the way up, the rate of marriage may be declining, and the age of first marriage is clearly being delayed. In 1995, 60 percent of American families were headed by a single parent, half of them never-married. Luker (1996) suggests two possible outcomes. The present situation may prove to be only a temporary deviation from a stable pattern of long-standing. Or it may mark the first hesitant appearance of an important new pattern.

If the latter interpretation turns out to have substance, one can ask why this is happening. Luker cites several influential shifts in social attitudes and behavior. First, “illegitimacy” has lost its moral sting. Second, many women are realizing that they do not need to put up with the abuse, domination, and other burdens they associate with married life. This has special resonance for women in poverty, who ask why they should live with a male who is unreliable and has no skills or job. Third, although welfare benefits are declining throughout the industrialized world, teenage pregnancies are on the rise regardless of the level of welfare benefits. Finally, the vast majority of teenage pregnancies are unintended and not linked with the availability of welfare aid.

So long as teenagers are sexually active, the most effective way to reduce the incidence of childbearing is to assure that they have access to contraception before the fact, and abortion, if needed, after the fact. The many Americans who oppose sexuality and contraceptive education in the schools, distribution of contraceptives in schools, and abortion can only hope that someone discovers a way to reduce teenage sexual activity itself. That seems unlikely, given the decreasing age of puberty among American youth, the declining age of first sexual intercourse, and the clear trend to delay marriage well into the 20s or even 30s. Admonitions to “Just say 'No'” are scarcely going to suffice as a workable national policy. In analyzing the politics of teenage pregnancy and single mothers in the United States, Kristin Luker (1996) concluded that:

Americans have every right to be concerned about early childbearing and to place the issue high on the national agenda. But they should think of it as a measure, not a cause, of poverty and other social ills. A teenager who has a baby usually adds but a slight burden to her life, which is already profoundly disadvantaged.... Early childbearing may make a bad situation worse, but the real causes of poverty lie elsewhere.

In America today, it seems that two camps are at war over the abortion issue. “Pro-choice” supporters advocate the right of the individual woman to decide whether or not to continue a pregnancy. They contend that the rights of a woman must take precedence over the “assumed” rights of a fertilized human egg or fetus. They believe that a woman can never be free unless she has reproductive control over her own body. Pro-choice advocates in the United States include various Protestant and Jewish organizations, Catholics for Free Choice, Planned Parenthood, the National Organization for Women (NOW), National Abortion Rights Action League (NARAL), and the American Civil Liberties Union (ACLU), among others.

Anti-abortion groups have politically identified themselves as “pro-life” supporters of “the right to life” for the unborn. This coalition involves such constituents as Eastern Orthodox, charismatic and conservative Roman Catholics, fundamentalist Protestants, and Orthodox Jews, in influential groups like Operation Rescue, Focus on the Family, and the Christian Coalition. These groups use various methods in order to prevent women from being able to have abortions, including, in some cases, personal intimidation of abortion providers and clients and political action.

The basic motivation of the protection of human life of those in the anti-abortion movement has, however, been questioned. For example, an analysis of the voting records of U.S. senators who are anti-abortion advocates indicates that they had the lowest scores on votes for family-support issues, bills for school-lunch programs, and for aid to the elderly (Prescott and Wallace 1978).

A Brief Legal History

As documented by Brodie (1994), early American common law accepted abortion up until “quickening” (movement of the fetus). Not until the early 1800s did individual states begin to outlaw abortion at any stage of pregnancy. By 1880, most abortions were illegal in the United States, except those “necessary to save the life of the woman.” However, since the right and practice of early abortion had already taken root in American society, abortionists openly continued to practice with public support and little legal enforcement. In the 1890s, doctors estimated that there were approximately two million abortions performed each year in the U.S. (Brodie 1994).

Before 1970, legal abortion was not available in the United States (Gordon 1976). In the 1950s, about one million illegal abortions were performed a year, with more than one thousand women dying each year as a result. Three quarters of the women who died from abortions in 1969 were women of color. Middle- and upper-class women, often with difficulty and great expense, could get “therapeutic abortions” from private physicians. By 1966, four fifths of all abortions were estimated to be for married women, and the ratio of legal to illegal abortions was 1 to 110.

In 1970, New York State passed legislation that allowed abortion on demand through the twenty-fourth week if it was done in a medical facility by a physician. However, on January 22, 1973, the U.S. Supreme Court decided a landmark case on abortion - Roe v. Wade. The Court stated the “right of privacy... founded in the Fourteenth Amendment's concept of personal liberty... is broad enough to encompass a woman's decision whether or not to terminate her pregnancy” (Tribe 1992). The major points of this decision were:

1. An abortion decision and procedure must be left up to the pregnant woman and her physician during the first trimester of pregnancy.

2. In the second trimester, the state may choose to regulate the abortion procedure in order to promote its interest in the health of the pregnant woman.

3. Once viability occurs, the state may promote its interest in the potentiality of human life by regulating and even prohibiting abortion except when judged medically necessary for the preservation of the health or life of the pregnant woman.

In addition, the Supreme Court has upheld various state laws that have been instituted to restrict abortions. In 1989, a Missouri law prohibiting the use of “public facilities” and “public employees” from being used to perform or assist abortions not necessary to save the life of the pregnant woman was upheld (Webster v. Reproductive Health Services). The court also upheld one of the strictest parental notification laws in the country in 1990 (Hodgson v. Minnesota). This law required notification of both of a minor's parents before she could have an abortion, even if she had never lived with them. Along with this restriction came a “waiting period” provision. A court decision in Rust v. Sullivan (1991) upheld a “gag rule” that prohibited counselors and physicians in federally funded family-planning clinics from providing information and making referrals about abortion. In 1992, the court upheld many restrictions set forth in a Pennsylvania law (Planned Parenthood v. Casey). These restrictions included requiring physicians to provide women seeking abortions with pro-childbirth information, followed by a twenty-four-hour “waiting period,” and parental notification for minors (Tribe 1992).

Nineteen years after the Roe decision, the Casey decision demonstrated that the Supreme Court was divided more sharply than ever over abortion. While a minority of justices wanted to overturn the Roe decision outright, the majority did not allow a complete ban of abortion. However, by enacting the “undue burden” standard, they did lower the standard by which abortion laws are to be judged unconstitutional. This standard places the burden of proof on those challenging an abortion restriction to establish that it is a “substantial obstacle” to their constitutional rights.

The various state laws now restricting abortion are particularly burdensome for younger and poorer women, and open the way for the creation of increasing obstacles to women's access to abortion. Currently, only thirteen states provide funding for poor women for abortions, and thirty-five states enforce parent-notification/consent laws for minors seeking abortions. At the same time, the Supreme Court has upheld the right to abortion in many cases.

The recent murders of physicians and staff at abortion clinics, arson and bombing of abortion clinics, and the blocking of abortion clinics by anti-abortion protesters have contributed to women's difficulty in receiving this still-legal medical procedure. Over 80 percent of all abortion providers have been picketed, and many have experienced other forms of harassment, including bomb threats, blockades, invasions of facilities, property destruction, assault of staff and patients, and death threats.

In 1988, Operation Rescue, the term adopted by anti-abortion groups, brought thousands of protesters to Atlanta to blockade the abortion clinics. Using an 1871 statute enacted to protect African-Americans from the Ku Klux Klan, the federal courts invoked injunctions against the protesters. However, in 1993, this decision was overturned, leading to Operation Rescue blockades of abortion clinics in ten more U.S. cities. The federal government moved to apply the Racketeer Influenced and Corrupt Organization (RICO) Act against such blockades on the grounds that it was a form of extortion and part of a nationwide conspiracy. This application of the RICO Act was upheld unanimously by the Supreme Court in 1994. Despite this protection, there has nevertheless been a serious decline in the number of facilities and physicians willing to perform abortions.

Current Abortion Practice

Legally induced abortion has become the most commonly performed surgical procedure in the United States. In 1988, 6 million pregnancies and 1.5 million legal abortions were reported. One in five women (21 percent) of women of reproductive age have had an abortion (Hatcher et al. 1994). If current abortion rates continue, nearly half of all American women will have at least one abortion during their lifetime.

Women having abortions in the United States come from every background and walk of life (Koch 1995). Abortion rates are highest among 18- to 19-year-old women, with almost 60 percent being less than 25 years old. One in eight (12 percent) are minors, aged 17 or younger. Of these minors, over 98 percent are unmarried and in school or college, with fewer than one tenth having had any previous children.

The vast majority (80 percent) of adult women having abortions are separated, divorced, or never married, with 20 percent currently married. One third of American women seeking abortions are poor. Almost half are currently mothers, with most of them already having two or more children. Half of the women seeking abortions were using a form of birth control during the month in which they conceived. About one third of abortion clients are employed, one third attend public school or college, and the other third are unemployed. The majority of women (69 percent) getting abortions are Anglo-American. Latinas are 60 percent more likely than Anglos to terminate an unintended pregnancy, but are less likely to do so than are African-American women.

Women with a more-liberal religious or humanist commitment are four times more likely to get an abortion than those adhering to conservative religious beliefs, according to Alan Guttmacher Institute surveys in 1991 and 1996. Catholic women are just as likely as other women to get abortions. Catholic women, who constitute 31% of the female population, had 31 percent of the abortions in 1996. In 1991, one sixth of abortion clients in the U.S. were born-again or evangelical Christians (Alan Guttmacher Institute 1991). In a similar 1996 survey, evangelical or born-again Christians, who account for almost half the American population, had 18% of the abortions.

Women give multiple reasons for their decision to have an abortion, the most important reasons being financial inability to support the child and inability to handle all the responsibilities of parenting. Three quarters of abortion clients believe that having a baby would interfere with work, school, or their other family responsibilities. Over half are concerned about being single parents and believe that the relationship with the father will be ending soon. Adolescent women, in particular, usually believe that they are not mature enough to have a child. One fifth of the women seeking an abortion arc concerned that either the fetus or they, themselves, have a serious health problem which necessitates an abortion. One in a hundred abortion clients are rape or incest survivors. Most abortion clients (70 percent) want to have children in the future.

Half of the abortions in the U.S. are performed before the eighth week of gestation and five out of six are performed before the thirteenth week (Hatcher et al. 1994). The safest and easiest time for the procedure is within the first three months. Most (97 percent) women receiving abortions during this time have no complications or postabortion complaints. Vacuum curettage is the most widely used abortion procedure in the United States, accounting for 97 percent of abortions in 1989. Intra-amniotic infusion is the rarest form of abortion performed, accounting for only 1 percent of abortions in 1989.

The weight of research evidence indicates that legal abortion, particularly in the first trimester, does not create short or long-term physical or psychological risks for women, including impairment of future fertility (Russo and Zierk 1992). In 1985, the maternal death rate for legal abortions was 0.5 per 100,000 for suction methods, 4.0 for induced labor, and one in 10,000 for childbirth (Hatcher et al. 1994).

Attitudes Toward Abortion

The National Opinion Research Center has been documenting attitudes toward abortion since 1972 (Smith 1996). Throughout this time period, public support for abortion under various circumstances has increased (see Table 8). The vast majority of Americans approve of abortion if a pregnancy seriously endangers the health of the mother, if the fetus has a serious defect, or if the pregnancy resulted from a rape or incest. Approximately half of the American public approves of abortion if the woman does not want to marry the father or if the parents cannot afford a child or do not want any more children. Close to half of Americans approve of abortion if the woman wants it for any reason. Level of education has the strongest effect on people's attitudes, with college-educated people being significantly more approving than those who are less educated. Catholics, fundamentalist Protestants, and Mormons who have a strong religious commitment are the most likely to disapprove of abortion. Anglo-Americans are somewhat more approving than African-Americans; men and adults under 30 are slightly more approving than women and adults over 65. In general, approval of legal abortion and the right of women to control their reproductive ability is associated with a broad commitment to basic civil liberties.

Table 8: Percentage of U.S.A. Adults Approving of Legal Abortion for Various Reasons

Reason	1972	1985	1996
Pregnancy poses serious health endangerment for woman	87.4	89.9	91.5
Strong chance of serious defect of fetus	78.6	78.9	81.1
Pregnancy resulted from rape	79.1	81.5	83.7
Parent(s) low income - cannot afford a child	48.9	43.2	45.7
Unmarried woman who does not want to marry father	43.8	41.2	44.3
Married woman who does not want more children	40.2	40.7	46.2
Woman wants an abortion for any reason	N.A.*	37.0	44.6

* Not asked

Source: Smith, T. W. (1996, December). Unpublished data from 1972-1996. General Social Surveys. Chicago: National Opinion Research Center.