Efforts to avoid an unplanned pregnancy.
Overall, nine in 10 women at risk of unplanned pregnancy use contraceptives themselves or have a partner who uses a method. Patterns and levels of contraceptive use vary by income, however (Figure 5; see page 18). (55)
* Roughly a third of at-risk women in each income group rely on sterilization, but lower income women are more likely than higher income women to have a tubal ligation and are much less likely to have a partner who has had a vasectomy. The disparity in vasectomy rates may reflect both that lower income women, especially those who are poor, are much less likely to be married, and that vasectomy is uncommon among blacks and Hispanics, (56) who are disproportionately poor.
* income women are slightly more likely than more affluent women to use the pill, but, overall, they are less likely to use reversible methods of contraception.
* Poor women are more likely than other women to have unprotected intercourse: Twenty percent of poor women at risk of unintended pregnancy use no contraceptive method, compared with 11% of low-income women and 8% of higher income women.
* Nonuse is more common among sexually active teenage women of all income levels: Twenty-two percent of poor teenagers aged 15-19 at risk of unintended pregnancy and 29% of low-income adolescents use no method, compared with 17% of higher income teenagers (not shown). (57)
More than half of all unplanned pregnancies occur among women who were not using contraceptives at the time. (58) Since virtually all at-risk, sexually active women have practiced contraception at some time (only 2% of all at-risk women aged 15-44, and 6% of those who are poor, have never used a method (59)), nonuse may frequently reflect gaps in relationships or method use rather than conscious decisions not to practice contraception or lack of awareness of its importance. Some women, however, do not use a method because of concern about side effects, because they or their partner dislike the methods available or because they have negative feelings about contraception in general. (60) Although women generally do not cite cost as a reason for not using a contraceptive, (61) it is likely that the expense involved is a barrier for some poor women, particularly those who want to use a method that requires frequent resupply or a medical visit.
Access to Services
Poor and low-income women, especially teenagers, depend heavily on publicly funded family planning clinics for their contraceptive care, because these clinics will accept Medicaid recipients when few other providers will and most offer subsidized services to lower income women who do not qualify for Medicaid. For women who do not have access to a family planning clinic, the cost of contraceptive care may be prohibitive: Private doctors typically charge $55-$89 for a new patient visit, excluding laboratory fees for Pap tests and sexually transmitted disease (STD) screening. (62)
Medicaid pays for the full range of contraceptive methods, including the contraceptive implant, Norplant, which normally entails significant up-front expense. Poor women who do not qualify for Medicaid can still obtain contraceptive services free of charge at the approximately 4,000 clinics (63) that receive Title X funding, provided they can locate and get to one.
Title X clinics are required to provide services on a sliding fee scale to women with incomes between 100% and 250% of the federal poverty level. Nearly nine in 10 Title X clinics charge women with incomes 25% above the poverty level ($9,200 a year for a single woman and $15,400 for a family of three) for an initial visit, and six in 10 charge for a three-month pill supply; the median charges are $15 and $6, respectively. (64)
Poor women who do not have access to a Title X clinic often have to pay for contraceptive services. About half of non--Title X family planning clinics typically charge poor women $50 for an initial contraceptive visit and a three-month supply of pills. Poor women who cannot afford those fees may be forced to rely on a method that they might find more difficult to use successfully, such as the condom (assuming their partners are willing to cooperate). Women with incomes at 125% of poverty are more likely to be charged for a clinic visit, and the median fees are higher than in Title X clinics: $24 for an initial visit and $19 for pills. (65)
Even in Title X clinics, however, client fees have accounted for a larger proportion of revenue in recent years. (66) There are several reasons for the increased reliance on fees:
* Title X funding declined 72% between 1980 and 1992 (when adjusted for inflation). (67)
* Costs for lab services and contraceptive supplies have risen. (68)
* Clinics have had to devote an increasing proportion of their funds to treat STDs and other medical problems among their clients. (69)
As a result of these trends, many clinics have been forced to cut back their hours of operation, accept fewer patients who need subsidized services and reduce their outreach efforts--changes that have made services less accessible to poor and low-income women. (70) Clinics' efforts to offer new contraceptive methods, such as the contraceptive implant and the injectable, have also increased the economic pressure on providers. (71)
Unplanned pregnancy rates among American women are high compared with rates among women in many other industrialized countries. (72) About 60%, or 3.3 million, of the 5.5 million pregnancies that occur annually in the United States are unplanned; (73) that is, they occur to women who wanted to delay having a baby until a later time or to women who did not want to have any children in the future. Women of all income levels experience accidental pregnancies, but those who are poor or low-income are much more likely than other women to become pregnant when they did not intend to: Three-quarters of pregnancies among poor women and more than two-thirds of those among women of marginal income are unplanned, compared with less than half of those among higher income women (Figure 6). (74)
Unplanned pregnancy rates are higher among poor and low-income women not only because they are less likely than higher income women to use a contraceptive method, but also because they have more difficulty using contraceptives correctly and consistently. Twenty-one percent of lower income women have an unintended pregnancy within the first year of use of their method, compared with 10% of higher income women. (75)
Like more affluent women, poor and low-income women who become pregnant unintentionally are faced with the dilemma of how to resolve their situation. Their lack of resources is an important factor in their decision-making.
(54.) AGI, 1994a.
Sixty-four percent of poor women, 65% of low-income women and 68% of higher income women are at risk of unintended pregnancy.
(55.) AGI, 1994a.
(56.) Forste, Tedrow and Tanfer, 1994; Mosher, 1990, Table 4, p. 201.
(57.) AGI, 1994a.
(58.) Harlap, Kost and Forrest, 1991, p. 33.
(59.) AGI, 1994a.
(50.) Silverman, Torres and Forrest, 1987, p.95.
(61.) Silverman, Torres and Forrest, 1987, P. 96.
(62.) Chapin, 1993.
(63.) AGI, 1992, p.3.
(64.) Henshaw and Torres, 1994, p. 58.
(65.) Henshaw and Torres, 1994, p. 58.
(66.) Henshaw and Torres, 1994, p. 59.
(67.) Daley and Gold, 1993, p. 248.
(68.) Henshaw and Torres, 1994, p. 59.
(69.) Donovan, 1991, p. 199.
(70.) Donovan, 1991, pp. 201-202; Moore, 1993, p. 3.
(71.) Frost, 1994; Henshaw and Torres, 1994, p. 59.
(72.) Jones et al., 1988.
(73.) Kost and Forrest, forthcoming, 1995.
(74.) AGI, 1994e; AGI, 1994f; Henshaw, 1992.
The total number of pregnancies excludes those that end in miscarriages.
(75.) Jones and Forrest, 1992, Table 4, p. 17.
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FIGURE 5 Contraceptive Use Most American women at risk of an unplanned preqnancy use contracep- tives; overall, poor women are less likely than other women to use a contraceptive method. Poor Low-Income Higher-Income Tubal ligation 29 31 22 Pill 31 28 27 IUD 2 2 2 Diaphragm 2 3 7 Condom 11 12 14 Vasectomy 2 8 13 Other 3 5 7 80% 89% 92% Women aged 15-14 at risk of unplanned preqnancy, 1988: 39, 286,000 Source: AGI, tabulations of data from the 1988 National Survey of Family Growth, 1994. Note: "Other" methods include spermicides, periodic abstinence and withdrawal. Note: Table made from bar graph FIGURE 6 Unplanned Pregnancy Pregnancies among women aged 15-44, 1988: 5,500,261 The majority of all pregnancies in the United States are unplanned. Poor and low-income women ar more likely than higher income women to become pregnant accidentally. PERCENTAGE UNPLANNED Poor 76% Low-income 70% Higher income 48% Sources: Abortions--AGI, tabulations of data from the 1987 AGI Abortion Patient Survey, 1994; and S.K. Henshaw, "Abortion Trends in 1987 and 19- 88: Age and Race," Family Planning Perspectives, 24:85-86, 96, 1992. Births--AGI, tabulations of data from the 1988 National Maternal and Infant Health Survey, 1994. Note: Pregnancies include those that end in births and abortions; those ending in miscarriage are not included. Note: Table made from bar graph
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|Title Annotation:||poor women's access to contraceptives and family planning service|
|Publication:||The Politics of Blame: Family Planning, Abortion and the Poor|
|Article Type:||Statistical Data Included|
|Date:||Jan 1, 1995|
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