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Achievements in Public Health, 1900-1999: Family Planning

During the 20th century, the hallmark of family planning in the United States has been the ability to achieve desired birth spacing and family size (Figure 1). Fertility decreased as couples chose to have fewer children; concurrently, child mortality declined, people moved from farms to cities, and the age at marriage increased (1). Smaller families and longer birth intervals have contributed to the better health of infants, children, and women, and have improved the social and economic role of women (2,3). Despite high failure rates, traditional methods of fertility control contributed to the decline in family size (4). Modern contraception and reproductive health-care systems that became available later in the century further improved couples' ability to plan their families. Publicly supported family planning services prevent an estimated 1.3 million unintended pregnancies annually (5). This report reviews the history of family planning during the past century; summarizes social, legal, and technologic developments and the impact of family planning services; and discusses the need to ensure continued technologic improvements and access to care.

Early History

Family size declined between 1800 and 1900 from 7.0 to 3.5 children (4). In 1900, six to nine of every 1000 women died in childbirth, and one in five children died during the first 5 years of life.* Distributing information and counseling patients about contraception and contraceptive devices was illegal under federal and state laws (8,9); the timing of ovulation, the length of the fertile period, and other reproductive facts were unknown.

In 1912, the modern birth-control movement began. Margaret Sanger (see box), a public health nurse concerned about the adverse health effects of frequent childbirth, miscarriages, and abortion, initiated efforts to circulate information about and provide access to contraception (9). In 1916, Sanger challenged the laws that suppressed the distribution of birth control information by opening in Brooklyn, New York, the first family planning clinic. The police closed her clinic, but the court challenges that followed established a legal precedent that allowed physicians to provide advice on contraception for health reasons. During the 1920s and 1930s, Sanger continued to promote family planning by opening more clinics and challenging legal restrictions. As a result, physicians gained the right to counsel patients and to prescribe contraceptive methods (10,11). By the 1930s, a few state health departments (e.g., North Carolina) and public hospitals had begun to provide family planning services.

During the first part of the 20th century, family planning focused on the need of married couples to space children and limit family size. Among a national probability sample** of 1049 ever-married white women born during 1901-1910 and interviewed in 1978, 71% reported having practiced contraception; common techniques used were the condom (54%), contraceptive douche (47%), withdrawal (45%), rhythm (24%), and the cervical diaphragm (17%) (12). Other reported methods included infrequent sexual intercourse (8%), intermittent abstinence (6%), and contraceptive sterilization (4%).*** Using abstinence to prevent pregnancy was limited by uncertainty about the timing of a woman's ovulation. In 1928, the timing of ovulation was established medically, but the safe interval for intercourse was mistakenly understood to include half the menstrual period (13). Nevertheless, by 1933, the average family size had declined to 2.3 children.

Modern Contraception

Family size increased from 1940 until 1957 (Figure 1), when the average number of children per family peaked at 3.7 (14,15; CDC, unpublished data, 1999). In 1960, the era of modern contraception began when both the birth control pill and intrauterine device (IUD) became available. These effective and convenient methods resulted in widespread changes in birth control (16). By 1965, the pill had become the most popular birth control method, followed by the condom and contraceptive sterilization (16). In 1965, the Supreme Court (Griswold vs. Connecticut) (17) struck down state laws prohibiting contraceptive use by married couples.

In 1970, federal funding for family planning services was established under the Family Planning Services and Population Research Act, which created Title X of the Public Health Service Act (18). Medicaid funding for family planning was authorized in 1972. Services provided under Title X grew rapidly in the 1970s and 1980s; after 1980, public funding for family planning continued to shift to the Medicaid program (18).

Since 1972, the average family size has leveled off at approximately two children, and the safety, efficacy, diversity, accessibility, and use of contraceptive methods has increased (Table 2). During the 1970s and 1980s, contraceptive sterilization became more common and is now the most widely used method in the United States (16,19,20). IUD use increased during the early 1980s, then declined because of concerns about intrauterine infections (16). In the 1980s and 1990s, the use of condoms increased among adolescents, presumably because of growing concern about human immunodeficiency virus infection and other sexually transmitted diseases (STDs) (21-23). Since 1991, increased use of long-acting hormonal contraception (Depo-Provera[Registered] [Pharmacia & Upjohn, Inc., Peapack, New Jersey] and Norplant[Registered] [Wyeth-Ayerst Laboratories, St. Davids, Pennsylvania])**** also have contributed to the decline in adolescent pregnancy rates (24,25). Emergency use of oral contraceptive pills might reduce the risk for pregnancy after unprotected intercourse by at least 74% (26). Noncontraceptive health benefits of oral contraceptives include lower rates of pelvic inflammatory disease, cancers of the ovary and endometrium, recurrent ovarian cysts, benign breast cysts and fibroadenomas, and discomfort from menstrual cramps (27).

In the United States, physicians are the primary providers of surgical sterilization, hormonal contraception, and IUDs. In 1994, 3119 agencies (e.g., health departments, Planned Parenthood affiliates, and hospitals) operated 7122 publicly subsidized family planning clinics for an estimated 6.6 million women (28). These services prevent an estimated 1.3 million unintended pregnancies annually (534,000 unintended births, 632,000 abortions, and 165,000 miscarriages) (5). Publicly supported clinics have been effective in supplying contraception to populations that have high rates of unintended pregnancy and have limited access to private health-care providers. In 1988, of the women who obtained reversible contraception, 22.5% overall received services from public clinics. Those most likely to receive these services were adolescent (43%), poor (39%), and never-married (34%) women (5).

Contraception Worldwide

The most important determinant of declining fertility in developing countries is contraceptive use, which explains 92% of the variation in fertility among 50 countries (29-31). Overall fertility declined by approximately one third from the 1960s through the 1980s, from an average of six to four children per woman (31), with dramatic decreases occurring in some parts of the world (e.g., 24% decline in fertility in Asia and Latin America, approximately 50% in Thailand, and approximately 35% in Colombia, Jamaica, and Mexico). As fertility declined in developing countries, the infant mortality rate decreased from approximately 150 deaths per 1000 live births in the 1950s to approximately 80 per 1000 in the early 1990s (2,3). Among married women of reproductive age in developing countries, 53% plan the size of their families (32); 90% of these women report using modern birth-control methods (e.g., female sterilization, oral contraceptives, and IUDs) (31).

Challenges

In the United States, unintended pregnancy remains a problem; 49% of pregnancies are unintended and 54% of these end in abortion (33). These rates remain significantly higher than rates of many other industrialized countries. During 1982-1986, among 15 Western countries with similar reproductive behavior (e.g., Canada, the Netherlands, and the United Kingdom), the United States ranked fourth highest in total fertility rate and had the second highest abortion rate and the highest pregnancy rate (34). Although pregnancy and childbearing rates for adolescent women have declined since 1991, the proportion of adolescent women who are unmarried at the time of giving birth has increased (24,25) from 15% in 1960 to approximately 75% in 1998.

Despite advances in family planning, population growth remains a worldwide concern. In 1999, world population reached six billion, an increase of 4.4 billion births since 1900 (35). In 1994, an international conference on population and development in Cairo focused international attention on the full scope of family planning that can be addressed during delivery of family planning services, including reproductive and primary-care concerns (36). For example, the introduction of cervical screening has led to a 20%-60% reduction in cervical cancer death rates (37). Screening programs for chlamydia, the leading cause of preventable infertility, can lower the prevalence of chlamydia and reduce complications such as pelvic inflammatory disease (38) The STD prevention benefits of family planning may be enhanced by new female-controlled barrier methods such as vaginal microbicides and the female condom.

Managed care is rapidly changing patterns of health-care delivery and creating new challenges for primary and reproductive health-care providers (39). Managed-care plans often offer more comprehensive coverage of such services than traditional insurance plans (39). In the late 1990s, legislatures in 19 states mandated partial or comprehensive insurance coverage for reversible methods of contraception (40). Access to high quality contraceptive services will continue to be an important factor in promoting healthy pregnancies and preventing unintended pregnancy in this country (41).

During the 20th century, restrictive policies and laws affecting family planning were largely replaced by legislative and funding support for family planning services by physicians and specialized reproductive health-care providers. Marshaling public support for efforts needed to reduce the high rate of unintended pregnancy and to provide the full array of reproductive health-care services remains a challenge.

Reported by: Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

References

  1. Bongaarts J. A framework for analyzing the proximate determinants of fertility. Population and Development Review 1978;4:105-32.
  2. Maine D, McNamara R. Birth spacing and child survival. New York: Columbia University Center for Population and Family Health, 1985.
  3. Potts M, Thapa S. Child survival: the role of family planning. Research Triangle Park, North Carolina: Family Health International, 1991.
  4. Commission on the Population Growth and the American Future. Population growth. In: Population and the American future. New York: New American Library 1972:9-21.
  5. Forrest JD, Samara R. Impact of publicly funded contraceptive services on unintended pregnancies and implications for Medicaid expenditures. Fam Plann Perspect 1996;28:188-95.
  6. Weed JA. Vital statistics in the United States: preparing for the next century. Population Index 1995;61:527-39.
  7. Mosher WD. Contraception. In: Wilcox LS, Marks JS, eds. From data to action: CDC's public health surveillance for women, infants, and children. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, 1994:29-37.
  8. Connell EB. Contraception in the prepill era. Contraception 1999;59:7S-10S.
  9. Wardell D. Margaret Sanger: birth control's successful revolutionary. Amer J Pub Hlth 1980:70:736-42.
  10. Perse T. The birth control movement in England and the United States: the first 100 years. JAMWA 1985;40:119-22.
  11. Gordon L. The politics of birth control, 1920-1940: the impact of professionals. International Journal of Health Services 1975;5:253-77.
  12. Dawson DA, Meny DJ, Ridley JC. Fertility control in the United States before the contraceptive revolution. Fam Plann Perspect 1980;12:76-86.
  13. Matsner EM. Contraception. In: Rosenau MJ ed. Preventive medicine and hygiene. New York: D. Appleton-Century Company, Inc., 1935:497-512.
  14. Taffel S. Trends in fertility in the United States. Rockville, Maryland: US Department of Health, Education, and Welfare, National Center for Health Statistics, 1978. Vital and health statistics, series 21, no. 28.
  15. Heuser RL. Fertility tables for birth cohorts by color: United States, 1917-1973. Rockville, Maryland: US Department of Health, Education, and Welfare, National Center for Health Statistics, 1976.
  16. Forrest JD. Contraceptive use in the United States: past, present and future. Advances in Population 1994;2:29-48.
  17. Griswold versus Connecticut, 381 US 479 (1965).
  18. Dryfoos JG. Family planning clinics: a story of growth and conflict. Fam Plann Perspect 1988;20:282-7.
  19. Mosher WD, Bachrach CA. Understanding U.S. fertility: continuity and change in the National Survey of Family Growth, 1988-1995. Fam Plann Perspect 1996;28:4-12.
  20. Chandra A. Surgical sterilization in the United States: prevalence and characteristics, 1965-1995. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, National Center for Health Statistics, 1998;20:1-33. Vital and health statistics--Series 23.
  21. CDC. Trends in sexual risk behaviors among high school students--United States, 1991-1997. MMWR 1998;47:749-52.
  22. Piccinino LJ, Mosher WD. Trends in contraceptive use in the United States. Fam Plann Perspect 1998;30:4-10,46.
  23. Sonenstein FL, Ku LC, Lindberg LD, Turner C, Pleck JH. Changes in sexual behavior and condom use among teenaged males: 1988 to 1995. Am J Public Health 1998;88:956-9.
  24. Kaufmann RB, Spitz AM, Strauss LT, et al. The decline in United States teen pregnancy rates, 1990-1995. Pediatrics 1998;102:1141-7.
  25. Ventura SJ, Curtin SC, Mathews TJ. Teenage births in the United States: national and state trends, 1990-96. National Vital Statistics System. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, National Center for Health Statistics, 1988, publication no. 98-1019.
  26. Van Look PFA, Stewart F. Emergency contraception. In: Hatcher RA, Trussell J, Stewart F, et al, eds. Contraceptive technology. 17th revised ed. New York: Ardent Media, Inc., 1998:277-95.
  27. Peterson HB, Lee NC. The health effects of oral contraceptives: misperceptions, controversies, and continuing good news. Clinical Obstetrics and Gynecology 1989;32:339-55.
  28. Frost JJ. Family planning clinic services in the United States, 1994. Fam Plann Perspect 1996;29:92-100.
  29. Westoff CF, Moreno L, Goldman N. The demographic impact of changes in contraceptive practice in third world populations. Population and Development Review 1989;15:91-106.
  30. Robey B, Rutstein SO, Morris L. The fertility decline in developing countries. Scientific American 1993;269:60-7.
  31. Robey B, Rutstein S, Morris L, Blackburn R. The reproductive revolution: new survey findings. Baltimore, Maryland: Johns Hopkins University, 1992. Population reports, series M, 11.
  32. Weinberger MB. Recent trends in contraceptive behavior. Proceedings of the World Conference on the Demographic and Health Surveys. Washington, DC: August 5-7, 1991.
  33. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24-9,46.
  34. Alan Guttmacher Institute. An international comparison of unintended pregnancy, contraceptive practice and family planning services. New York: Alan Guttmacher Institute, 1987.
  35. United Nations. World population prospects, 1998 revision, vol 1: comprehensive tables. New York: United Nations, 1999.
  36. Alan Guttmacher Institute. The Cairo consensus: challenges for U.S. policy at home and abroad. Issues in brief. New York: Alan Guttmacher Institute, 1995.
  37. Report of the US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Alexandria, Virginia: International Medical Publishing, Inc., 1996.
  38. Scholes D, Stergachis A, Heidrich FE, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydia infection. N Engl J Med 1996;334:1362-6.
  39. Alan Guttmacher Institute. Reproductive health services and managed care plans: improving the fit. In: Alan Guttmacher Institute. Improving the fit: reproductive health services in managed care settings. New York: Alan Guttmacher Institute, 1996.
  40. The Henry J. Kaiser Family Foundation. Issues in brief: an update on women's health policy. Menlo Park, California: The Henry J. Kaiser Family Foundation, November 1999.
  41. Wilcox LS, Koonin LM, Adams MA. Quality measures for unintended pregnancy in managed care: opportunities and challenges. Women's Health 1999;9:250-8.

* Along with family planning improvements came the public health surveillance systems needed to track population fluctuations. In 1900, the standard U.S. death certificate was created, augmenting the 1880 national death registration area (6) (Table 1); in 1915, the national birth registration area was created, combining state systems into a national system. In 1955, Growth of American Families, the first national survey of women to measure reproductive factors such as the use of contraception, infertility, and pregnancy intentions, was conducted using private funding (7). Five cycles of the federally sponsored National Survey of Family Growth (in 1973, 1976, 1982, 1988, and 1995) have continued to provide data on contraceptive methods, the use of family planning services, and other information on reproductive health of women (cycle six will include men).

** Weighted data, adjusted to the 1950 census of white, ever-married women by age, education, urban-rural residence, and number of live-born infants.

*** Although 4% reported contraceptive sterilization, 28% reported having surgery before aged 50 years that rendered them infertile.

**** Use of trade names and commercial sources is for identification only and does not imply endorsement by CDC or the U.S. Department of Health and Human Services.



Table 1

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TABLE 1. Milestones in family planning -- United States, 1900-1997

1900

First standard certificate of death created

1914

Margaret Sanger arrested for distributing birth control information

1915

First federal birth registration area created

1916

First birth control clinic, Brooklyn, New York (closed after 10 days by the New York Vice Squad)

1925

First manufacture in the United States of diaphragms

1928

Timing of ovulation established

1937

American Medical Association endorses birth control

1937

First state (North Carolina) includes birth control in a public health program

1942

Planned Parenthood Federation of America established

1955

First national fertility survey conducted

1960

The birth control pill approved by Food and Drug Administration (FDA)

1960

Intrauterine device approved by FDA

1965

Supreme Court (Griswold vs. Connecticut) declares unconstitutional state laws prohibiting contraceptive use by married couples

1970

Family Planning Services and Population Research Act creates Title X of the Public Health Service Act

1972

Medicaid funding for family planning services authorized

1973

Supreme Court (Roe vs. Wade) legalizes abortion

1973

First National Survey of Family Growth conducted

1990

Norplant®* approved by FDA

1992

Depo-Provera® approved by FDA

1993

Female condom approved by FDA

1997

Emergency use of oral contraceptive pills approved by FDA

* Use of trade names and commercial sources is for identification only and does not imply endorsement by CDC or the U.S. Department of Health and Human Services.


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Figure 1

Figure 1
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Table 2

Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 2. Efficacy of commonly used methods of contraception* and percentage of couples using the method -- United States, 1995

 

% women experiencing unintended pregnancy in first year of use

 

Contraceptive method

Perfect use

Typical use

% couples using the method

Implant (Norplant® and Norplant-2®)

0.05%

0.05%

1.3%

Male sterilization

0.10%

0.15%

10.1%

Pill

0.1%

5.0%

24.9%

Injectable (Depo-Provera®)

0.3%

0.3%

2.7%

Female sterilization

0.5%

0.5%

25.6%

Intrauterine device

0.6%

0.8%

0.7%

Condom (male)

3.0%

14.0%

18.9%

Withdrawal

4.0%

19.0%

2.9%

Diaphragm

6.0%

20.0%

1.7%

Spermicides

6.0%

26.0%

1.3%

Periodic abstinence

9.0%§

25.0%

2.2%

* For spermicides, periodic abstinence, the diaphragm, male condom, and pill, these estimates for typical use were derived from the experiences of married women in the 1976 and 1988 National Surveys of Family Growth (NSFG) and of all women in the 1988 NSFG. The estimates for the intrauterine device, sterilization, Depo-Provera®, and Norplant® were from large clinical investigations. The estimate for withdrawal was based on evidence from surveys. Perfect use is a best guess of the probabilities of method failure (pregnancy) during the first year of perfect use, i.e., when it is used consistently according to a specified set of rules. Highly rigorous scientific data are available to support estimates for implants, sterilization, pill, and the IUD. Use of trade names and commercial sources is for identification only and does not imply endorsement by CDC or the U.S. Department of Health and Human Services.
† Copper T 380A.
§ Calendar.

Sources:

Trussel J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart F, et al, eds. Contraceptive technology, 17th revised ed. New York: Ardent Media, Inc., 1998:779-844.
Trussel J, Kowal D. The essentials of contraception. In: Hatcher RA, Trussell J, Stewart F, et al, eds. Contraceptive technology, 17th revised ed. New York: Ardent Media, Inc., 1998:211-47.


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