Understanding U.S. fertility: continuity and change in the National Survey of Family Growth, 1988-1995

About 50 studies based on the 1988 National Survey of Family Growth (NSFG) and a telephone reinterview conducted with the same women two years later provide continuing information about the fertility and health of American women. Among the findings of these studies are that black women have almost twice as many pregnancies as do white women (5.1 vs. 2.8), with nearly all of the difference being unintended pregnancies. Unwanted births increased between 1982 and 1988, particularly among less-educated, poor and minority women. This increase in the proportion of unwanted births may have prompted the increase in female sterilization among these groups. Concern with the AIDS epidemic led to increases in condom use between 1982 and 1990, especially among the partners of teenagers and college-educated women. Rates of teenage pregnancy were fairly stable during the period 1980-1988, as increases in the proportion of teenagers having intercourse were offset by increases in condom use. Rates of infertility did not change significantly in the 1980s, but because of delayed childbearing and the aging of the baby-boom cohort, the number of older childless women increased substantially. The 1995 NSFG was redesigned in a number of ways in order to answer a new generation of questions about fertility and women's health in the United States.

Orgasm without organisms: science or propaganda?

The worldwide epidemic of sexually transmitted diseases (STDs) presents a major public health challenge to medical practitioners and educators as they seek to implement preventive educational strategies in the adolescent population. The serious consequences of many STDs and the insufficient impact of condom promotion in this high-risk group have led to increasing recognition that sexual intercourse is medically unwise for young adolescents. As a result of this recognition, some educators have proposed that adolescent sexuality education focus on the explicit teaching of noncoital sexual activities, sometimes called outercourse. This paper explores the emergence of this educational strategy, the assertion that noncoital sexual activities will positively impact the rising incidence of STDs and unplanned pregnancy in teenagers, and the hypothetical benefits of adolescent noncoital sex.

Consequences for children of their birth planning status

Of 1,327 children younger than two in 1986 whose mothers were participants in the National Longitudinal Survey of Youth, 61% were wanted, 34% were mistimed and 5% were unwanted. Planning status is associated with the level of developmental resources the child receives at home: At ages one and older, mistimed and unwanted children score significantly lower on a scale measuring opportunity for skill development and on a scale measuring nonauthoritarian parenting style than their wanted peers; by preschool age, they also have significantly less-positive relationships with their mothers. Measures of the direct effects of planning status on development also indicate that mistimed and unwanted children are at a disadvantage: Those younger than two have higher mean scores for fearfulness than wanted infants and lower scores for positive affect; unintended preschoolers score lower on a measure of receptive vocabulary.

Adolescent parenting: outcomes and maternal perceptions

OBJECTIVE

To describe selected outcomes and maternal perceptions of adolescent parenting.

DESIGN

Qualitative and quantitative methods, interview, and two standardized instruments were combined in this follow-up study of adolescents who received perinatal services between 1985 and 1988.

SETTING

Data were collected in the mothers' homes.

PARTICIPANTS

Mothers who were randomly selected for an earlier chart outcome audit (N = 98) and could be located (n = 19).

MAIN OUTCOME MEASURES

Subsequent pregnancies; school completion; children's development, indicated by the Developmental Profile II (DPII); parental attitudes, indicated by the Adult-Adolescent Parenting Inventory (AAPI); and maternal perceptions.

RESULTS

Responses revealed irregular use of contraceptives as one reason for the initial pregnancy and for subsequent unplanned pregnancies. Sixteen mothers completed high school, and 18 intend to complete postsecondary programs. The DPII indicated age-appropriate development of the children. AAPI scores for 84% of the mothers indicated nonnurturing attitudes. Mothers described family support, motherhood, and their children.

CONCLUSIONS

Research is needed with larger samples and to test interventions to promote regular use of contraception. Findings support the need for research-based programs to educate and promote the development of adolescent mothers and their children.

Meeting the needs of young adults

As they mature and become sexually active, more young people face serious health risks. Most face these risks with too little factual information, too little guidance about sexual responsibility, and too little access to health care. Meeting young adults' diverse needs challenges parents, communities, health care providers, and educators. Despite urgent needs, program efforts have been slight and slowed by controversy.

Termination of pregnancy and psychiatric morbidity

BACKGROUND

We investigated whether reported psychiatric morbidity was increased after termination of pregnancy compared with other outcomes of an unplanned pregnancy.

METHOD

This was a prospective cohort study of 13,261 women with an unplanned pregnancy. Psychiatric morbidity reported by GPs after the conclusion of the pregnancy was compared in four groups: women who had a termination of pregnancy (6410), women who did not request a termination (6151), women who were refused a termination (379), and women who changed their minds before the termination was performed (321).

RESULTS

Rates of total reported psychiatric disorder were no higher after termination of pregnancy than after childbirth. Women with a previous history of psychiatric illness were most at risk of disorder after the end of their pregnancy, whatever its outcome. Women without a previous history of psychosis had an apparently lower risk of psychosis after termination than postpartum (relative risk RR = 0.4, 95% confidence interval CI = 0.3-0.7), but rates of psychosis leading to hospital admission were similar. In women with no previous history of psychiatric illness, deliberate self-harm (DSH) was more common in those who had a termination (RR 1.7, 95% CI 1.1-2.6), or who were refused a termination (RR 2.9, 95% CI 1.3-6.3).

CONCLUSIONS

The findings on DSH are probably explicable by confounding variables, such as adverse social factors, associated both with the request for termination and with subsequent self-harm. No overall increase in reported psychiatric morbidity was found.

Teenage pregnancy: a comparative study of teenagers choosing termination of pregnancy or antenatal care

A comparative study of 167 pregnant teenagers in Devon attending either antenatal booking clinics or for National Health Service (NHS) termination of pregnancy was carried out to determine differences in their characteristics, use and experience of local family planning services. Teenagers presenting for termination of pregnancy were younger and more likely to say that they had wished to avoid getting pregnant. Whether the teenager was in a stable relationship was strongly associated with the outcome of the pregnancy, with single girls being more likely to choose a termination of pregnancy. The termination of pregnancy group were also more likely to be condom users, and to have learned about their method of contraception from school rather than from health care professionals. Teenagers' frequency of contact with family planning services suggested that teenagers choosing a termination were less likely than antenatal attenders to have attended regularly. This was mainly due to differences in behaviour among teenagers attending their general practitioner (GP) for contraceptive advice: teenagers having a termination were more likely to describe their visit to their GP as embarrassing. These findings have implications for local family planning services attempting to reduce the number of unwanted teenage pregnancies.

Intention status of U.S. births in 1988: differences by mothers' socioeconomic and demographic characteristics

The National Maternal and Infant Health Survey provides new data on the prevalence of unintended childbearing in the United States: Thirty-six percent of births in 1988 were mistimed and 7% were unwanted, while 57% were intended. Although the level of unintended childbearing is high in almost all socioeconomic subgroups of women, the proportion of births that were mistimed or unwanted was 50% or more among age-groups 15-17 (78%), 18-19 (68%) and 20-24 (50%), and among never-married women (73%), formerly married women (62%), black women (66%), women living below the federal poverty level (64%) or at 100-149% of the poverty level (52%), women with less than 12 years of education (58%) and women who already had two children (53%) or three or more children (60%). Multivariate analyses indicate that births to unmarried women--whether formerly married or never-married--are less likely than those to married women to be wanted and more likely to be mistimed. Poverty status has no independent effect on the odds that a birth is unwanted or on the odds that a birth to an unmarried woman is mistimed. Among currently married women, those who are poorer are more likely than women above 150% of the poverty level to have a mistimed birth. Black women are more likely than either Hispanic or white women to report a birth as unwanted and are more likely than white women to say a wanted birth was mistimed.

Maternal deaths among women with pregnancies outside of family planning in Sichuan, China

To assess the impact of family planning status on maternal mortality, we analyzed data gathered in a community-based, maternal mortality surveillance study conducted by the Sichuan Health Department in the People's Republic of China during 1989-1991. The overall maternal mortality ratio, which included only deaths of pregnant women within family planning guidelines ("planned" pregnancies), was 78.9 per 100,000 livebirths. When the deaths of pregnant women outside of family planning ("unplanned" pregnancies) were included, the maternal mortality ratio doubled to 135.6 per 100,000 livebirths. The leading causes of death for women with "planned" and "unplanned" pregnancies were the same: hemorrhage, postpartum infection, pregnancy-induced hypertension, cardiac diseases, and pulmonary diseases. As among women with "planned" pregnancies, about 40% of maternal deaths among women with "unplanned" pregnancies occurred at home, and 20% occurred en route to a hospital. After controlling for the confounding effects of gravidity and education, the odds ratio of maternal death associated with "unplanned" pregnancy status was 2.6 [95% confidence interval (CI) = 2.0-3.7], which declined to 2.0 (95% CI = 1.4-2.9) with additional control for the effect of prenatal care visits. Our study indicates that women with "unplanned" pregnancies have a higher risk of maternal death, which is only partially attributed to less prenatal care.

Which is more important to high school students: preventing pregnancy or preventing AIDS?

A sample of about 2,900 high school students in greater Miami, Florida, was surveyed to determine their attitudes toward pregnancy prevention vs. AIDS prevention and how these attitudes affect condom use. Female, Hispanic and black respondents were the most likely to consider pregnancy and AIDS prevention to be equally important. White non-Hispanics and males were relatively more likely to believe that preventing pregnancy is less important than preventing AIDS, whereas males and females involved in a steady relationship placed more emphasis on pregnancy prevention than AIDS prevention. The more knowledge about HIV and AIDS a respondent had, the less importance he or she placed on pregnancy prevention, and as the importance of preventing pregnancy declined, so did the frequency of condom use. Males who were in a steady dating relationship and perceived pregnancy prevention as more important than AIDS prevention were the most likely to report using condoms often.

Pregnancy among American Indian adolescents: reactions and prenatal care

PURPOSE

Adolescent childbearing is twice as common among Native Americans as among all US races combined. Despite this, little is written about the psychosocial context or prenatal care of pregnant Native American adolescents. The objective of this study was to explore the reactions and prenatal care of Navajo and Apache adolescents delivering infants at Shiprock Indian Hospital, New Mexico, between January and March 1991, and Whiteriver Indian Hospital, Arizona, between May and June 1991.

METHODS

Of the 25 eligible adolescents aged 19 years and younger, 15 Navajo and 5 Apache participants were interviewed within 24 hours of delivery. The interview consisted of 121 questions divided into 5 areas: sociodemographics, personal and family reactions to the pregnancy, knowledge and attitudes toward prenatal care, barriers to care, and ways to improve access to care.

RESULTS

The mean age was 17.4 +/- 1.1, 6 were married, and 13 were primiparous. According to the Maternal Health Services Index, 5 adolescents received adequate, 13 intermediate, and 2 inadequate prenatal care. During the pregnancy, 3 adolescents used tobacco, 3 used alcohol, and none admitted to other drugs. Although only 1 adolescent planned the pregnancy, 15 were not using contraception when they became pregnant. In exploring reactions to the pregnancy, 13 adolescents were afraid to tell their families and 4 concealed the pregnancy until confronted. During the pregnancy, 7 adolescents described loneliness and 6 expressed suicidal ideation. Although over half reported no barriers to obtaining prenatal care, barriers that were noted by the remainder included transportation, family problems, and missing school.

CONCLUSION

We conclude that pregnancy among many American Indian adolescents is unplanned and characterized by uncertainty and fear of disclosure, resembling the reactions to pregnancy of other adolescent populations. Furthermore, despite universal access to health services, many American Indian adolescents continue to experience barriers to care and receive intermediate or inadequate prenatal care. These preliminary findings suggest further research may help clarify how adolescent reactions to pregnancy and knowledge of prenatal care affect health care utilization.

Epidemiology of unintended pregnancy and contraceptive use

Almost all women are at risk for unintended pregnancy throughout their reproductive years. However, adolescents, formerly married women, and women of low socioeconomic status are at greater risk for contraceptive nonuse and for contraceptive failure; thus they are also at greater risk for unintended conceptions. Of the 6.4 million pregnancies occurring in the United States in 1988, more than half (56%) were unintended. An equal proportion of unintended pregnancies end in abortion (44%) as with birth (43%), and both options have great personal and social consequences. The level of unintended pregnancy appears to have increased during the last decade after consistent decreases since the early 1960s. Decreasing both the periods of contraceptive nonuse and contraceptive misuse will help lower the rate of unintended pregnancy in this country.

Induced abortion. Effects of marital status, age and parity on choice of pregnancy termination

OBJECTIVE

To study the impact of marital status, age and parity on the decision regarding pregnancy termination over time among pregnant Norwegian women.

DESIGN

National surveillance data of induced abortions and births.

MATERIAL

All women terminating their pregnancies (n = 174,590) as registered in the Abortion File in the Central Bureau of Statistics and all women giving birth (n = 639,551) as registered in the Medical Birth Registry of Norway between January 1, 1979 and December 31, 1990 were eligible for the study. Included in the analysis of pregnancy outcome were records with complete information on marital status, age and parity, which comprise 93.8% (n = 163,826) of all women having had an induced abortion and 99.0% (n = 633,542) of all women giving birth during the time period.

OUTCOME MEASURE

The proportion of pregnancies terminated as induced abortions and the relative risk of pregnant women choosing abortion in strata of marital status, age and parity.

STATISTICAL METHODS

Trend analysis of the proportion of pregnancies terminated as induced abortions in different time periods in categories of marital status, age and parity.

RESULTS AND CONCLUSION

From the first three-year period 1979-81 to the last three-year period 1988-90 there was a decreasing tendency to choose abortion among unmarried pregnant women above 20 years of age and married women with two or more children. In the other strata of marital status, age and parity there were no changes over the time period, except for married women 20-24 years of age which was the only group that showed an increasing abortion tendency over the time period. The prospect of single parenthood was the strongest determinant for choosing abortion independent of age and parity. Within all age groups of married women the abortion tendency increased more with parity than age. Cohabiting women chose abortion significantly more often than married women did. However, the true estimate of choosing abortion among cohabiting women was closer to married women than to single women. In order to find out the importance of other social factors and attitudes in the decision making process regarding pregnancy outcome, adjustments must be made for marital status, age and parity.

Adolescent perceptions of adoption. Implications for resolving an unplanned pregnancy

This research examines the attitudes and perceptions that adolescents have of adoption. Of particular interest is how these attitudes might help to explain the decline in the choice of the adoption alternative as a way of resolving an unplanned pregnancy. Although participants appear to have generally favorable attitudes toward adoption, there were high levels of uncertainty about how parents and friends would feel about adoption. In relation to other pregnancy resolution alternatives, adoption is the least discussed option. Finally, many were uncertain about how to go about adoption and there were perceptions that making an adoption plan was complicated and of questionable legality.

Some aspects regarding teenage pregnancy in Denmark

The 'Scandinavian model' is often mentioned as the one that upholds citizens' rights and encourages an opened-minded and honest discussion of problems. This article focuses on unplanned teenage pregnancies in Denmark. During the period 1974 to 1990 the number of live births to women in the age group 15 to 19 years almost halved. During the same period there was only a 20% reduction in the number of legal abortions. The legal abortion rate is considered to be relatively high, and initiatives taken to reduce the rate are elucidated. Special attention is paid to topics such as access to information on contraceptives and the extent to which adolescents use the knowledge they have acquired. Another topic of discussion is the influence of AIDS on younger people with regard to the use of contraceptives. Strategies are suggested that might reduce the number of unplanned teenage pregnancies.

Effects on Navajo birthrate from loss of the intrauterine device

The concerns of relatively powerless groups may not be adequately addressed by health-care decisions based on market forces and on considerations of the general population. Calculations of the number of Navajo women at risk of unintended pregnancy suggest that several hundred such pregnancies would have occurred as a result of the withdrawal of intrauterine devices from the United States' market. Analysis of birthrate data confirms this estimate: approximately four to five percent of Navajo births in 1988 may have been due to this market withdrawal. Available data are limited in their ability to assess impacts on small groups of health-policy decisions made for the population as a whole. A mechanism for surveilling such effects needs to be established to protect the interests of such groups, particularly when they have restricted alternatives.