Enacting religious beliefs in a pluralistic society.

PIP: The question of fetal life and "personhood" is inherently religious since science cannot determine that a fetus becomes a person at conception. The Hyde Amendment, which prohibits Medicaid funds from being used for abortions, is predicated on the religious idea that a fetus is a person. It was designed to prevent the "slaughter of innocent, inconvenient, unwanted children." The Hyde Amendment is an example of enacting religious beliefs in a pluralist (secular) society. The legislative discussion in Congress and the language of the Amendment are of a religious nature, espoused by the "Right To Life" lobby, supported by religious groups, and directed by the Catholic Bishops' lobbyist. Consensus on the personhood of a fetus is not possible in that it is a metaphysical question. Public policy neither mandates nor prohibits the use of contraception, but there is still no consensus on the morality of contraception.^ieng

Observations on birth planning in China, 1977.

PIP: The People's Republic of China has a national family planning program which encourages late marriage, small families, and long birth intervals. The program attempts to make modern contraceptive, sterilization, and abortion services easily accessible. The birth planning program in 2 communes - Wan-Tou and Chang-Ching - is described in detail. In both communes, propaganda teams seek to reeducate the people to the new norms. Nearly 90% of all eligible women are using some form of birth control; in Wan-Tou more than 60% are using IUDs and less than 10% have been sterilized while in Chang-Ching the proportions are reversed. Both communities view family planning as legitimate and place a high priority on it. Traditional views regarding male superiority and the desirability of large families are the main obstacles to the family planning program. Regional variations exist in contraceptive preferences but practice is higher than 90% throughout the country. Municipal records, a sample of which is discussed, are used to monitor progress. The program has succeeded in lowering the birthrate since the early 1960s but more effort will be needed in the future.^ieng

Sounding board. The pill: a perspective for assessing risks and benefits.

PIP: Over the past 17 years, a "contraceptive revolution" has occurred, based on highly effective methods which can be applied at a time unrelated to sexual intercourse. In the 1950s, birth control was thought to be a settled issue for the middle and upper class. Although motivated to limit family size, low-income women found the diaphragm and condom inappropriate for their life style. Between 1960-1965, Planned Parenthood's caseloads of low-income women tripled. By 1975, nearly 4 million women of low and marginal income were clinic patients, with 72% choosing oral contraceptives. Those who advocate replacing the pill because of medical risk with coitally related methods are ignoring the needs of many low-income women in the U.S. Tietze et al. have shown that except for older women who smoke, the risk of mortality from using any method of fertility control is lower than the risk from automobile accidents or from childbirth. A more comprehensive framework is needed for weighing the total benefits expected by contraceptors against the total risks of any particular method. We also need an enlarged research program for safer contraceptives; a higher priority in the National Institutes of Health budget.^ieng

Estimating family planning program effects on U.S. fertility rates.

PIP: An evaluation was undertaken of the effects on U. S. fertility rates of the national family planning program. 1968-1969 family planning enrollment data were linked to 1970 census data in the same areas to derive an objective measure of the impact of organized clinical family planning programs on the 1969-70 fertility rates of subgroups of women defined by age, race, marital status, economic status, and racial composition of their area. Multivariate modelling was used to control for spurious effects of irrelevant variables. Results of the multivariate modelling show significant reductions of marital fertility among the low socioeconomic groups served by the program; no effects were exhibited by groups not served. Cumulative fertility of all groups, black and white, at all age and socioeconomic levels was affected by the program. A plausible explanation for these results lies in antecedent factors which led to the presence or absence of family planning clinics in any particular area in 1969 and its 1969 enrollment level. Communities more favorably disposed to provision of birth control services would have been more likely than other areas to apply for federal funding of family planning programs when it became available in the middle 1960s. Due to an earlier start, their programs were flourishing by 1969.^ieng

Short-term benefits and costs of U.S. family planning programs, 1970-1975.

Between 1969 and 1975, the U.S. family planning program helped its patients avert 1.1 million unwanted and mistimed births. These averted births resulted in short-term savings to the government for health and social welfare services of $1.1 billion, compared to a federal investment in family planning of $584 million--a benefit/cost ratio of $1.80 for every federal dollar invested.

Funding for reproductive research: the status and the needs.

Just to maintain the admittedly inadequate level of research in reproduction and contraceptive development attained in 1974 would require an investment of $143 million this year--a level that has not been reached. To take advantage of existing knowledge, at least $361 million would be required--increasing to $498 million by 1980. To achieve a high-priority research program--10 percent of health expenditures--would require $500 million this year--rising to $766 million by 1980.

Fertility control services for adolescents: access and utilization.

More than one million teenagers get pregnant each year; six in 10 pregnancies end in live births--the rest in induced or spontaneous abortions. More than one-third of the births are out of wedlock. Yet, two-thirds of teenage pregnancies and half of the births are not intended. Some two million teenagers at risk of unintended pregnancy are now using effective birth control methods; but two millions are still denied them.

Family planning program effects on the fertility of low-income U.S. women.

Under rigorous statistical controls, it has been shown that the larger the proportion of lower SES women enrolled in organized family planning programs, the lower their fertility. Program effects independent of other social, economic and cultural factors were shown for lower SES whites and blacks, and for most age groups. The potential of a fully implemented program to reduce fertility differentials between upper and lower SES groups was assessed, using 1969-1970 fertility rates and the estimates of 1969 program impact. Although we believe that the program's impact has increased in magnitude over time, even these estimates from an early point in U.S. program development provide impressive documentation that the program reduces fertility in the subpopulation served by the program, and, by implication, that there is a genuine need for organized family planning services, even in an industrialized nation like the United States. If there were no need, there could be no program effect. The family planning program was one of the major new health and social programs introduced in the mid-1960s. This study shows that, far from failing, the program was succeeding very well in attaining its objectives. The program works because it gives women of lower socioeconomic status access to modern and effective methods of contraception that they would not otherwise have. As a result, the rates of unwanted and mistimed pregnancy of patients are lower than those of comparable women who lack access to organized clinic programs.

Abortion need and services in the United States, 1974-1975.

More than one million legal abortions were performed in the United States last year--but one-half to three-quarters of a million women in need of abortion services were still unable to obtain them. Ninety percent of all abortions are now performed in the woman's home state, but services are still highly concentrated within states--typically in one or two metropolitan centers where most services are provided by nonhospital clinics. Only one-fourth of hospitals-and fewer than one-fifth of public hospitals-provide any abortion services. Many poor, rural and teenage women who can least afford to travel to obtain legal abortions will continue to be denied access to the services they want and need.

Reproductive efficiency as a social indicator.

An index of reproductive effiency (RE) is proposed as a social indicator that will meet the need to consider various forms of pregnancy wastage, to compare their relative costs, and to guide reproductive health policy accordingly. This article discusses conceptual and measurement aspects of RE. Conversion of wanted to unwanted pregnancies and the reverse, interpretation of abortion in relation to other pregnancy outcomes, defining the end point for the reproductive process and criteria for the events to be included as significant outcomes are conceptual issues. Measurement problems include: whether aggregation is justified, prospective and retrospective tracking of outcomes, record limitations, duplication of adversities in a single pregnancy, and selection of optimal rate for comparison. A measurement of RE for the entire United States based on the National Natality Survey of 1964-1966 is presented, showing 74.5 percent of pregnancies resulting in healthy liveborn infants. For those years, data on abortions could not be included. Within the group of reported pregnancy losses, the importance of congenital abnormalities and low-birth-weight babies is enhanced by application of economic weights based on associated medical care costs. Changing opportunities for birth timing, prenatal and infant care, and control of family size are social means of reducing adverse outcomes associated with teenage pregnancy and high-parity births, often found together with poverty. Successive increments in RE may be progressively more expensive to achieve, and cost effectiveness comparison will be necessary.

An index of insurance adequacy for fertility-related health care.

Health insurance plans are evaluated here in terms of ability to guarantee financial access to a set of basic fertility-related health services. Extent of coverage is determined by whether a service is a contract benefit, its market cost, and how often it is used in a given population in one year. Comprehensive coverage removes a deterrent to utilization of preventive care such as well-baby visits, prenatal care, and family planning. In a total population of women of child-bearing age, each is likely to need some fertility-related care in a given year. The method of calculating adequacy involves using best available estimates of deliveries, abortions, etc. per 1,000 women, and, within each category, of components such as cesarean section. Local or national cost data can be used to derive an average cost per service and an aggregate for a group. The method of comparing this with plan benefits depends on the way benefits are expressed. Jacksonville, Fla. medical market data were used in a trial of the method on a plan for Federal employees, which shows 70 per cent coverage of estimated expense.

Data gaps in planning for comprehensive fertility-related health services.

PIP: Using aggregate national data, an attempt was made in 1972 to estimate the numbers of persons who will need each of the fertility-related services (e.g., prenatal and postnatal care for wanted pregnancies, medical care of infant in its first year fertility limitation, and medical treatment of infertility) between then and 1978, and the costs of providing them. The preliminary model was later refined utilizing additional sources of data are needed to help the health care system assist individual members of the community to achieve their family formation goals. The paper includes discussions of the sorts of data that are needed and the reasons for this need, the present sources of data (in terms of providers, households, payers, and carriers), and the types of data gaps (absence, insufficient disaggregation, lack of relatedness, in complete specification). The author contends that attention to the various gaps would increase the potential of our important national surveys to produce data on numbers in need of fertility-related health services, etc. Greater comparability in questions asked and in methods of analyzing and presenting the responses could be achieved at little sacrifice of the basic purposes for which the systems were created. Recommendation is made that a step be taken to convene a small conference of key personnel working on these systems to explore the gaps and incompatibilities, propose means of overcoming them, and identify needed special studies.^ieng