CONTRACE

THE U T I M Z A T I O N OF C CE ION COHO FOR T ... EV UATI OF F I PL NING P GR

ION

S S*

R o y G. S ith, M.D., M.P.H. Schools o f Public H e a l t h and M e d i c i n e

Patricia G. S t e i n h o f f , Ph.D. D e p a r t m e n t o f Sociol y J a es A. P a l m o , Ph.D. Dep tment of Sociology C!a l o t t e Payne, M.S., M.A. R ou es E d u c a t i o n Specialist U n i v e ~ i ty o f Hawaii H o n o i u l u , Hawaii

ABSTR

T

Data were collected f r o m w o m e n Ilo conceived d u r i n g specified periods fro 1971 t h r o u g h J u n e 1973 in o r d e r . t o d e t e r m i n e ' ( a ) t h e t o f p l a n n e d and u n p l a n n e d c o n c e ~ tion t h r o u g h o u t the state, over t i m e and by clinic service ea; and (b) the elm cteristics which are k n o w n to i n f l u e n c e fertility b e h a v i o r (age, aritai status, and etllnic g r o u p ) o f t h o s e o m e n w h o failed to plan t h e i r c o n c e p t i o n s . T h e s e d a t a w e c o m pa d with t h e clia cteristics o f w o e s e ed by tlle family p l a n n i n g ciinics in various are to d e t e r m i n e w h e t h e r services were beio e x t e n d e d to high risk ~ o u p s . these a as vided order

E v a l u a t i o n o f the g r o u p s in n e e d o f s e ice in each clinic a a, and c o m p a r i s o n o f findings with the characteNstics o f w o en a c t u a l i y served b y the cl1,~lc, i d e n t i f i e d wl~ere se ices ere n o t being di c t e d to ~ o u p s in need. T h e s e a a di rences pr e x a m ples o f sit ua tions po ten tially a m e n a b ! e t o a p p l i c a t i o n o f evaluation resu 1~ in to give d i r e c t i o n t o faro ily p l a n n i n g se ices.

Accepted

for publication

March

2, 1976

* This paper was originally presented at the Annual Meetings of the Population Association o f A A ] I 19, 1975.

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fica,

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CTION

Historic~ifly, ily p l a n n i n g p r o g r s l m v e b e e n c o n c e ed w i t h p r e v e n t i n g u n p l a n n e d p r e g n a n c i e s a n d a l l o w i n g a p p r o p r i a t e s p a c i n g a n d ti i n g o f p r e g n a n c i e s ....It is o n l y recently that fertility d u c t i o n a n d Io e r e d p o p u l a t i o n g w t h ratesoh e b e e n i d e n t i f i e d as p r i n c i p a l g o a l s o f a n y p r o g r a s. In e l u a t i n g fa i l y p l a n n i n g p r o g ms, h o w e v e L t w o t y p of easures h e ~nerally b e e n u s e d . D e o ph , on the one hand, have been pri arily concerned witli ea~ u s of fertility reduction e w l l e n this w a s n o t t h e s t a t e d of o s t fa ily p l a n n i n g p until latively cently. Family planningse ice p e ~ o n n e l , o n t h e o t I l e r h a n d , h a v e b e e n pri a r i l y c o n c e r n e d w i t h easu s ofse ice~ T h e indices ost quently ed ..b. y t h i s l a t t e r ~ o u p h a v e b e e n t h e n u 10er o f c o n t c e p t i v e s d i s p e n s e d , t h e n u m b e r o f female (and, rely, ale) accepto~, the nu her of dropouts fro clinic records, and the number of pe~ons lost to folio u p .... T h e r e c e n t d e v e l o N n e n t o f a c o n c e for fertility r d u c t i o n as a g o a l o f f a ly p l a n n i n g p o l i c i is, o f c o u r s e , legiti ate. N e v e r t h e l e s s , t h e r d u c ti o n o f fe r ti I i t y m a y be a c c o plis h ed b y m a n y ea ns, n o t all o f w h i c h (e. g., i n d uc ed abortion) a directly lated to family planning prog s. H e n c e , i f e a concerned a b o u t t 11e r e d u c t i o 11 o f fe r t i Ii t y t h r o u g h c o n c e p fi o n p Ia n n i ng, c h a n g ~ i n i i v e bi rt 1i r a t es a n o t t h e o n l y i n d i c a t o m w e s h o u l d s t u d y t o e v a l u a t e t h e r e l a t i v e s u c c e s s o f a fa ily p l a n ning prog . Ttm present paper illustrates how, using data fro c o n c e p t i o n c o h o r t , it is p o s s i b l e t o d e t e r m i n e tile e c t i v e n e s s o f fa i l y p l a n n i n g p r o g r a m s b y i d e n t i f y i n g tlle relative p r o p o r t i o n s o f u n p l a n n e d p g n a n c i e s t h a t o c c u r t o p e ~ o n s ho a the target popuiations for family planning prog m efforts. m .... t e ctively the characteristi T o d i r e c t tt e~ t l l r u s t o f a f a ily p l a n n i n g p r o ~ a of o m e n n e e d i n g f a m i l y p l a n n i n g se ices ( o e n h o h a v e failed t o p l a n t h e i r p g n a n t i e s ) sh o u!d b e i d e n ti fie d a n d t h ese s h o u l d b e r e l a t e d t o s peci fi c g e o g r a p l l i c a r e a s w h i c h clinics a r e s p o n s l b e f o r serving. W i t h s u c h k n o w l e d g e a v a i l a b l e t o p l a n n e r s a n d d i c t o o f f a m i l y p l a n n i n g p r o g m s , se ices c o u l d b e t a i l o r e d ore specifically toward specific g upsofwomen. M e a su m e n t t h e w o u Id b e: ( a ) t r e n d s o v e r t i m e o f pI a n e d v e ~ us u n p! ala n e d p r e ~ n a n c i e s in e a c h c l i n i c se ice a r e a ; ( b ) c l i a n ~ s o v e r ti e in t h e c t l a r a c t e f i s t i c s o f t h e w o m e n w h o a ~ failing to use c o n t c e p t i o n e c t i v e i y in e a c h c l i n i c s e i c e a r e a ; a n d ( c ) c h a n t s over time the characteristics of omen c e i v i n g se ices f r o tile c l i n i c in e a c h s e r v i c e a r e a t o d et e r m i n e i f t 11e p r o p o r t io n o f t h o s e ~ o u p s i d e n ti fie d a t h i g h e r ri s k h a s b e e n i no a s e d in tl!e ~ m i l y p l a n n i n g c l i n i c p o p u l a t i o n . Tiffs a n a l y s i s u t i l i z e s c o n c e p t i o n c o l l o r t s . E a c h c o l l o r t is a ~ o u p o f o en w h o all b e c a m e p r e N l a n t d u n n g t h e sa e s p e c i f i e d ti e p e r i o d . Tiffs is t h e ost appropriate g u~ ing t o s t u d y ~ r s e s s i n g ti e t r e n d s in c o n c e p t i o n p l a n n i n g . W h i l e o n e c study arria c o h o r t s o r b i r t h c o t i o r t s f o r a ~ e ing f e r t i l i t y r a t e s o r f e r t i l i t y r e d u c t i o n , a n sess e n t o f conception planning requir the study of those h o c o n c e i v e d u r i n g t h e ti e p e r i o d u n d e r study.

D

A SOURCES

D a t a o i l n a a t e r n i t y a n d a b o r t i o n p a t i e n t s w e r e c o l l e c t e d b y tile H a aii P r e g n a n , Birth Control and Abortion Study fro hospitai r e c o ~ s and self-ad i ~ s t e r e d q u e s t i o n n a i r e s ( c o m p l e t e d v o l u n t a r i l y ) a t all h o s p i t a l s in t h e s t a t e o f H a w a i i in w h i c h a b o r t i o n s a r e performed. Th e data were collected dunng t onth periods twice a year on mate ity patients, and througtlout the year on abortion patien~.~( e l a t t e r ti e s p a n as n e c e s s a ~

516

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1976

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13 N O .

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CE

abortions a pe the u t e r u s a n d t h u s t h o u g h tllis is .)

I ON

i t t e d in t h e s t a t e a t a n y ti e p r i o r t o t h e viabiliv$ o f t h e f e t outside ay b e p e r f o r m e d as !ate as t h e t w e n t ~ s i x t h e k o f g r a t i o n , al-

F t h e s e data, c o n c e p t i o n c o h o r ~ we cons cted for t h e alysis o f c o n t cepti use, c o n c e p t i o n p l a n n i n g , a n d the d i s p o s i t i o n o f u n p l a n n e d c o n s. E a c h c o n c e p t i o n c o h o r t i n c l u d e s all pre a n c i e s c o n c e i d a t a gi n t e w h i c h c o u l d sult in live birtl~. T h e baseline f o r t h e c o h o ~ w t h e li bi s whi occu d during a tw onth period. T h e p r o b a b l e c o n c e p t i o n m o n t h s f o r these li b i r t h s ere c a l c u l a t e d , a r ch all c o n c e p t i o n s hich c o u l d e occur d d ng the p bable conception on d i s u i t e d in i n d u c e d a b o ~ i o n w e a d d e d t o t h e li birth~ The conception cohort t h u s c o n s i s t e d o f ii bir which sul~d con ptio in a s p e c i f i e d t i ~ e p e r i o d plus abo~ions which s u i t e d f r o c o n p t i o n s o n l y in t e ti e p e r i o d . * e following conception c o h o r ~ C o h o r t 4" C o h o r t 5" C o h o r t 6C o h o r t 7"

disc

sed in this

April-May, i'971 c o n c e p t i o n s (Janua~-Feb a ~ , 1 9 7 2 li bi

p,

t.t

s)

Janua F e b a ~ , 1972 c o n c e p t i o n s (October-N e be 1 9 7 2 i i v e b i ) A u g u s t - S e p ~ her, 1972 c o n c e p t i o n s ( M a y - J u n e , 1973 li births) Feb y-Ma h, 1973 c o n p t i o n s ( N o v e b e ~ D e c e her, i 9 7 3 live b i r t h s )

In a d d i t i o n to tlle c o n c e p t i o n c o h o ~ d a ~ , d ~ a e c o l l e c t e d on fa ily p l a n n i n g se ices i n t h e s t a t e ....T h e H a aii PI n e d P n t h o o d C o p u r r C e n t e r p vided d a t a l!ected fro fa ily p l a n n i n g clinic p a t i e n t s d 1972 a n d 1973. T h e d a t a extensively re m a t t e d f o r this alysis, in o r d e r t o p u c e an u n d u p l i c a t e d c o u n t o f w en w h o visited a n y o n e o f the s ta t e ~s ily p l a n n i n g clini d u g a onth period i me diately p ding t h e c o n c e p t i o n o n t h s o f a c o n p t i o n c o h o S . In this p o r t , clinic d a t a e o n l y u s e d i t h the l a s t c ption coho~(C o r t 7). T h e fa ily pl n i n g s e r vice p e r i o d was S e p t e ber, 1 9 7 2 t ~ o u g h J a n u a ~ , 1973. DEFiNiT!

OF C

F o r t h e analysis o f p l a n n e d a n d unp! been ope tionally defined . . . . . (a) (b)

C

P

ned c o n c e p t i o n s , a "'pla

e d c o n c e p t i o n " has

Occurring when contraception as n o t ~ e d specifically b e c a u s e t h e w o an i n t e n d e d t o b e c o e p ant; and te i n a t i n g in e i t h e r a live b i r t h o r ~ i n d u c e d a b o ~ i o n .

A n " u n p l a n n e d c o n c e p t i o n " has b e e n o (a)

TI

A con d

p t i o n te

tionally defined

i n a t i n g in a live bi ~.

or indu

" d a

~ion which

s not meet condition (a)a

*

e data w e ~ adj ted ~ightiy so that e a ~ cohort repre n~ ~rtu y MI ~ a ~ d p~gnan~es in the state ~ r ~ a t timepen . r a o det edexplanaU o f pro dures, e ( 1 ) a n d ( 2 ) . t Cohor~ 1 and 2 ~ ~ p~.abor~on law liberalization. Cohort 3 w re rted m (1).

APRIL

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13 N O .

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517

CONTRACE

ION

With the above definitions in i n d , w h e t h e r a c o n p t i o n w a s " p a1 n n e d'" o r " unplanned" was dete ined by the wo an's qu tionnai sponses. Tile levant q u tionnai ite s u s e d t o d e ~ ine p l a n i n g s t a t u s h a v e b e e n r e p o r t e d in d e t a i l else e (I). E B u

s

ATION MEASU

e d o n tile a b o v e d e f i n i t i o n a n d t h e d a t a d ere c o n s t r u c t e d "

I.

S USED cribed p

vio

ly, f o u r e v a l u a t i o n

eas-

nt of p ancies w h i c h e p l a n n e d is is a si p l e pe e n t d i s t r i b u t i o n of the pregnancies for a particular sub~oup within one conception cohort. Figures a b a s e d o n all able r e p h s to the p!anning question, weighted to co ct for questionnaire no response.

2 Rt.'t

of planned and unplanned p nan F o r this easu , rates of pregnancy w e r e c a l c u i a t e d u s i n g s t a n d a rd d e o g r a p h ic tecl m i q u es a d a p t e d t o t h e d a ta f r o t h e co n e e p t i o n c o h o r ts. T h e pe roe n t o f pi an n e d a n d u n p! a n n e d p r e g n a nci es i n tlle cohort was applied to the e I! p g n a n c y tes t o p r o d u c e e s t i a t e d r a t e s o f planned and unplanned pre~ c y p e r t h o u s a n d w o en.

P gnancy rates a b a s e d o n all k n o w n c o n c e p t i o n s in t h e s t a t e d u r i n g a t w ontll period h i c h e i t h e r r e s u l t e d in live b i r t h s o r w e r e t e r i n a t e d b y i n d u c e d a b o r t i o n ( s p o n t a n e o u s abortions, e c t o p ic p gnancies and stillbirtlis a o itted). The tw m o n t h p e r i o d is ed the idpoint of a on year period. The totaI nu ber of c o n c e p t i o n s d u r i n g t h e o n ~ y e a r ~ p e r i o d is d e t e r i n e d , u s i n g an a p p r o p r i a t e s e a s o n a l c o r r e c ti o n. T h e p r e gn a n cy m te is t he n c a !c u ! a t e d b y a p p! y in g t 1~s t o t a | o f p gn a ncies in t h e s t a t e t o an n u al Iy a d j u s t e d ce ns u s figu s f o r al I w o e n in t h e s t a t e age d 1 5 - 4 4 y e a r s . T h e p e r c e n t o f p gna ncies an n e d a n d u n p l a n n e d is o b t a i n e d f r o the qu tionnai sa p i e o f t h e c o n c e p t i o n :cohort a n d a p p l i e d t o tile e 1! r a t e t o p d u c e esti a t e d t of planned and unplanned conception. I n s o f a r as p o s s i b l e , d a t a o n arital status refer t o a f i t a l s t a t u s a t t h e ti e o f nception. Howeve~ for aternity patients lao d i d n o t r p o n d t o t h e q u e s t i o n n a i , a n t a l s t a t u s i n f o r a t i o n w a s o b t a i n e d f r o m h p i t a l r e c o r d s at ti e o f d e t i v e ~ . T h i s p r o d u c e s an u n d e sti a t e o f p r e g n a n c i e s t o single w o e n a n d a c o r r e s p o n d i n g o sti ate o f pregnancies t o a r r i e d w o en in t h e y o u n g t age g r o u p s .....°Based o n t h e pe e n t o f q u e s t i o n n a i s p o n d e n ~ w!ao c h a n g e d arital°status single t o arried between concepti on and deliverw ul t i p l i e d b y t h e pe e n t o f m a r n e d o e n w h o did n o t r e p l y t o t h e q u e s t i o n nai , w e calcuI a t e t h e a o u n t o f overe s t i a t e in t h e arried cat~o~ t o b e as f o l l o s" Age Cohort Cohort Cohort Cohort

4 5 6 7

i 5-19

2ff

17.3% 14.3% 16. 13.8%

5.7% 4.6% 4. i % 7.9%

T h e uncle sti a ~ in t h e r a t e o f p gnanci t o single w o e n c a n n o t be e s t i a t e d exactly in t h e s e pe e n r a g e s , w h i c h a p p l y ~ t h e ..n u m b e r o f ses in t h e n u e r ~ tor of the tes. en i t h o u t r ~ c a i c u l a ~ o n o f t h e r a t e s , it is c i e a r t h a t r a t e s o f p g n a n c y a o n g single t e e n a ~ even higher than ~ p o r t e d , by a considerable deg e

518

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13

NO.

4

C

T

CE

ION

3. R a °of p l a n n e d a n d u n p l a n n e d p n d i n & se ar Zip code bounda r i e s w e r e u s e d t o d e f i n e t h e se ice p o p u l a t i o n ~ a r e a s o f fa ily p l a n n i n g clinics. T h e ore traditional boundaries of census tr could not be ed b e c a u s e a c t u a l add ~es of women receiving abortions we u n a v a i l a b l e . All a as o f t h e s t a t e w e r e i n c l u d e d in t h e a iysis, w l l e t h e r o r n o t t h e w a s a c l i n i c t o se e t h e ca. i n s o m e c es, zip c o d e a as w e r e c o b i n e d t o a p p r o x i a t e m o t i m e l y ti!e a c t u a l l l o m g e n e o u s a a se ed b y a n y clinic. in order to calculate a~-and atria s~cific tes of planned and unplanned conc e p t i o n f o r zip c e a r e a s in t h e s t a t e , i t w a s n e c e ~ a w t o k n o w t h e e x a c t p o p u l ~ t i o n o f all t h e z i p c o d e a as b y s e x , a ~ , a n d arital status..The info ation was obtained the data tape 1970 ns Fiftil urit S u m m a r y T a p e , F i l e B. All cen Sus d a ta b y zi p c o d e a as an d c o u n ties w ere a n n u al i y a us t e d t o 1 9 7 3 . Sin ce c e n s u s i n f o n n a t i o r i b y z i p c o d e is n o t given f o r age a n d m a r i t a i s t a t u s c o m b i n e d , r a t e s o f p l a n n e d a n d u n p l a n n e d c o n c e p t i o n b y clinic se i a r e a s c a n be a g ~ s p e c i fi c o r m a ~ i a g o s p e c i fi c, b u t n o t a c o b i n a t i o n o f b o t h . C l i n i c se tes.

ice a r e a r a t e s w e

c a l c u l a t e d b y t h e sa

e procedu

s used for state-wide

4. R a t o f nic e by cl~ic serv~e a Patientrecordsforeachfa ilyplanning c l i n i c d u r i n g tile five m o n t h s p r i o r t o tlle t a ~ e t c o n c e p t i o n p e r i o d ~o f c o n c e p t i o n c o h o r t 7 ( S e p t e m b e r i, i 9 7 2 - J a n u y 3 i, 1 9 7 3 ) w e used t o calculate age and m a r i t a l - s t a t u s - s p e c i f i c tes o f c l i n i c use t o t h e a p p p r i a t e z i p c o d e a n d county a as. A s e a s o n a l c o ~ e c t i o n o f 2.3 8 5 6 was e p l o y e d t o a d j u s t tlie case l o a d s f o r t h e f l y , m o n t h p e r i o d t o o n e y e a r to c o r r e s p o n d w i t h . p o p u l a t i o n figu ; T h i s p ced u r e s ta n d a r d i z e s t h e c l i n i c case ! o a d in t e s o f tile se lc.'e a r e a ' s p o p u lation characteristics, and permi~ lnore meaningful comparison between the clinic d a t a a n d t h e s e r v i c e a a n e e d s as m e u d b y tes o f u n p l a n n e d p g n a n c y . T h e s e f o u r m eas ures w e r e an aly ze d f o r fo u r c o n ce p t i o n c o h o r t s t o p rovid e a n s w e ~ t o the following questions" 1. I n t h e t h r . e y e a ~ 1971 - 1 9 7 3 , w laa t w e r e t h e t r e n d s i n p r e ~ a ~ cy pl a n n i n g i n t h e state of Hawaii? What groups we having high and lo proportions of their preD n a n c i e s p l a n n e d , a n d flow did this c h a n g e o v e r ti e? 2 ....As o p p o s e d t o a si p i e i n c r e a s e in d e l i b e r a t e d e c i s i o n s t o b e c o m e p r e g n a n t , t o w h a t e x t e n t w e r e c h a n g e s in t h e p l a n n i n g o f p r e ancies a t t N b u t a b l e to i p r o v e d use o f contraceptive eth s to p vent the occurrence of unplanned p gnancies? 3. In 1 9 7 3 , w h a t ~ o u ~ e in p a r t i f a r n e e d o f s e se e d b y fa i|y p l a n n i n g c!inics i n t h e s t a t e ?

ices in t h e ~

4. In i 9 7 3 , h o d i d t h e se i s p r i d e d b y f a m i l y p t a n n i n g c i i n i n e e d s i d e n t i f i e d in t h e se i p o p u l a t i o n o f t h e a a?

APRIL

1976

L.

13

NO,

4

raphic a~as

co

s p o n d tO t h e ....

.~19

CONTRACE

ION

RESU

Tre l)dsinpla

e da n

S

ed Pregn an cies

D u r i n g t h e y e a ~ 197 I- 1 9 7 3 , tlle p r o p o r t i o n o f w o m e n w h o

ported that they

planned t o b e c o m e p r e g n a n t i n c ~ a s e d f r o m 4 4 p e r c e n t ( c o h o r t 4 ) t o 5 4 p e r c e n t (colaort 7). H o w e v e r , tll ese figures n o t i n d i c a t e w h e t h e r t h e inc e in p e r c e n t o f p g n a n c i e s p l a n n e d i s d u e to a l a r ~ r n u h e r o f w o m e n d e c i d i n g t o b e c o m e p r e ~ a n t , o r t o a d e c r e a s e in t h e o c c u r n e e o f u n p l a n n e d pregnancies. If it we d u e t o a larger n u m b e r o f w o m e n d e c i d i n g to b e c o m e p r e g n a n t , t h e n t h e i n c ~ a s e w o u l d n o t r e p r e s e n t a n y real i p r o v e e n t in t e r m s o f f a m i l y p l a n n i n g p r o g r a e rts, since t h e a c t u a l v o l u e o f u n p l a n n e d p n a n t i e s w o u l d n o t n e c e s sari I y ii ave bee n red u ce d. T h e rea s o n for t h e i n c r e a s e i n t h e pe rcent o f p gnancies p l a n n e d c be clarified b y e x a m i n a t i o n o f t h e t nd in t h e r a t e s o f p l a n n e d a n d u n p la n n e d p r e g n an cy per t h o a n d w m e n a ~ d 15-44. D u r i n g tile t h r e e y e a ~ u n d e r s t u d y , t h e r e was a small d e c l i n e in t h e erall p g n a n c y rate fro I 1 2 to 107 p e r t l a o u s a n d (see T a b l e I). While t h e rate o f p l a n n e d p ~ a n c y w e n t u p d u r i n g t h e p e r i o d , t h e r a t e o f u n p l a n n e d p r e g n a n c y d e c l i n e d even m o r e . , t h e inc r e a s e b e t w e e n i 9 7 1 a n d 1973 in tile p e r c e n t o f p r e g n a n c i e s w h i c h w e p l a n n e d is d u e b o t h t o m o r e w o m e n h a v i n g p l a n n e d p r e g n a n c i e s a n d t o fewer w o en b e c o ing p r e g n a n t unintentionally. A i t h o u g h b o t h f a c t o ~ we o p e r a t i n g , t h e d e c ase in t h e r a t e o f unp l a n n e d p r e g n a n c y a c c o u n t s for m o o f t h e t o t a l d e c l i n e in p r e g n a n c i e s . Since the plliiosophy o f v o l u n t a ~ ily p l a n n i n g seeks t o l i m i t c o n c e p t i o n s tO t h o s e w h i c h are plan ne d, t h e s e figures are q ui te e n c o u r a g i ng. Tilere was a co nsi d e ble r e d u c t i on in t h e r a t e o f u n p l a n n e d p r e g n a n c y d u r i n g this p e r i o d , 66 p e r t h o u s a n d in 1 9 7 2 ( c h o r t 5 ) t o 4 9 pe r t h o u s a n d i n i 9 7 3 ( c o h o r t 7 ). De sp i t e a n i n c re as e i n t ~ ra t e o f p ! a n n eel p a n c y , t h e r e was a d e c r e a s e in the o l! r a t e o f p r e g n a n c y . T h e negligible d e c l i n e in t o t a l p g n a n c i e s m a s k s tile large d e c l i n e in u n p l a n n e d p gnancies. T h e a m o u n t o f i n c r e a s e in the p r o p o r t i o n o f p r e g n a n c i e s w h i c h w e r e p l a n n e d , a n d t h e r e a s o n s for t h e i n c r e a s e , vary w i t h the oW an s i tal s t a t u s , age, a n d e t h n i c i t y . T h e s e va ri a ti o n s w i I 1 be e x a m i n e d i n d e t ail, ut i i i z i n g b o t l! t i!e pe ~ e n t o f p g n a nc i es wll i c h w e r e plan n e d , a n d rates o f pla n n e d an d u n p l a n n e d p r e g n a n c y . Bo th t y p e s o f a n a l y s i s a r e qui d f o r a c l e a r u n d e r s t a n d i n g o f w h a t c a t e g o r i e s o f w o en r e m a i n o s t in n e e d o f fa i!y plann i n g se ices.

1. Age a t t d

rita! Smtus. ~Botll age a n d m a r i t a l s t a t u s ha b e e n s h o w n to have m a j o r effects on the tes o f p i a n n e d a n d u n p l a n n e d p g n a n c y (2). B y 1 9 7 3 , u n p l a n n e d p ~ g n a n c y r a t e s h a d b e e n c o n s i d e r a b l y l o w e r e d a o n g m a r r i e d w o en in ost a ~ g r o u p s . T h e h i g h t r a t e s o f u n p l a n n e d p g n a n c i e s w e r e f o u n d a o n g single w o en in t h e i r t w e n t i e s , d i v o0 r c e d or w i d o w e d w o en aged 20, and m tied women u n d e r 20. In e a c h o f t h e s e ~ o u p s , ughly one o an in t e n h a d an u n p l a n n e d p g n a n c y in 1 9 7 3 . M o r e o v e r , in e a c h o f t h e s e g ups, e x c e p t a r r i e d w o en t i n d e r 20, t h e g a t m a j o r i t y o f all gnancies we u n p l a n n e d . H o w e v e r , all t h r e e g r o u p s s h o w e d a n i n c ase in pe e n t o f p g n a n c i e s p l a n n e d 1971 ( c o h o r t 4 ) to 1973 ( c o h o r t 7 ) a s s h o w n in F i g u r e 1. Analysis o f t h e r a t e s o f p l a n n e d a n d u n p l a n n e d p r e g n a n c y d u r i n g this ti e p e r i o d i n d i c a te s t! 1a t i n ~ pr ov e en t i !! a v o i d i n g U n p i a n n e d p g n a n c y (i. e . , s u c c e ss fu I c o n , t r a c e p t i o n ) was c o n f i n e d al o s t e n f i r e i y t o arried w o en ( T a b l e I ) . I n 1971 (c h o r t 4), t h e tes o f u n p l a n n e d pre cy we a b o u t t h e sa e f o r arried (61) and d i v o ed o r w i d o w e d w o en (6 0) a n d s l i g h t l y h i g h e r f o r single w o m e n (6 8). T h e o r e I! p g n a n c y r a t e f o r a~ied wo en as o f c o u p e uch higher because of the

APRIL

1976

VOL.

13

NO.

4.

CONTRACEPTION

T A B LE I M a r r i a g e - S p e c i f i c Rates o f P l a n n e d and U n p l a n n e d

P r e g n a n c y a p e r 1 , 0 0 0 W o m e n , A g e d 15-44, 1 9 7 1 - 1 9 7 3 b

Marital s t a t u s ...... . _

_,

_

.~

~.................

~:-

-

-

__

1971

1972

1973

1974

Cohort 4

Cohort 5

Cohort 6

Cohort 7

(N = 3 , 1 6 2 ) c =

.....

:::

~

--

-~

_~-.

-~

_

_

-:

~.~

-

-:

= -

,. . . . . . . .

~

:.

~_

- - -

j:J,u

(N - 3 , 5 0 7 ) c . . . .

~_

~

. . . .

:~:~-::

,,,,,,,,,,,,,,

.

-

.

.

.

.

.

(N - 3 , 0 9 8 ) c .

.

.

.

.

.

.

.

.

.

:

-

.

_

(N - 3 , 4 8 9 ) c - .

~

j~,,,,~,~-

~

-

-

::

....

~

-

:

Single P l a n n e d pregnancies U n p l a n n e d pregnancies

9 68

12 72

12 68

19 67

All p r e g n a n c i e s

77

84

80

86

12

14

15

22

73 61

73 62

74 51

80 40

134

135

125

120

54

54

59

67

6 60 66

11 72 83

22 69 91

15 66

9

13

24

18

49 63 1 12

50 66 1 16

52 57 109

58 49 107

44

43

48

54

Perccnt planned Married P l a n n e d pregnancies U n p l a n n e d pregnancies All pregnancies

.Percent planned D i v o r c e d and w i d o w e d Planned pregnancies U n p l a n n e d pregnancies All pregnancies

Percent planned

81

All women P l a n n e d pregnancies U n p l a n n e d pregnancies All pregnancies

Percent planned

a Pregnancy rates are calculated from all pregnancies in the state applied to total state population of women aged 15-44. The percent of pregnancies planned and unplanned is obtained from the questionnaire sample of the conception cohort and applied to the overall rate to produce estimated rates of planned and unplanned pregnancie~ ~ b Pregnancy rates are based on all conceptiOns i n t h e state during a two-month period which either resulted in live births or were terminated by i ~ u c e d abortion. This period_ Was used ~ the midpoint in determiningall conceptions for a one-year period, with appropriate seasonal adjustment. Base conception ~ r i o d s for these rates are as follows" Coh0rt4, April-May, 1971 ; Cohort 5, January-February, 1972; Cohort 6, ~August-Septem~~ 1972; Cohort 7, February-March, 1973. c N is the number of pregnancies from which the planning status was determined. The N for each marital status exceeds 79 for each cohort_ SOURCES" Pregnancy data from Hawaii Pregnancy, Birth Control and Abortion Study Conception Cohorts 4, 5, 6, 7; population data from 1970 U.S. Census, with annual adjustment through 1973 calculated by M. Choe and J. Nakagawa.

APRIL

1976

VOL.,

13

NO

4

.521

CONTRACE

ION

i001 ,% N =

% L. . . . . . . . . . . . . . . . . . . . . . . . . . _ ...........................

F 40 % n= 1iO

22 % n=~3

nz!|3

14 '%

9% I

0

==

4

5

6

7

SINGLE WOMEN

......................~ .. 5 6 ....................

4 M (I N

L

FIGURE

ENT

4 R

EN S SE

MARl

...........

7 ED)

5

6

D OR Wl WOMEN

7 ED

US

I

NANCI ICH WERE MAR! L US, I I ~ 1 3 ( ION COHORTS 4, 5.6, 7!

ANNED

la nu her of planned pregnanci in this g up. B y 1973 ( c o h o r t 7), tile t e o f unplanned pregnancy ong m a led w o en h a d d r o p p e d b y a t h i r d , t o 4 0 per t h o u s a n d , b u t t h e r e as n o d u c t i o n in t h e rat o f u n p l a n n e d p g n a n c y for single ( 6 7 ) o r d i v o r c e d a n d w i d o w e d w o e n ( 6 6 ) . H e n c e , b y 1973 t w o o u t o f t h r e e p r e ~ nanciesof a ed w o e n w e p l a n n e d ; o n l y o n e o u t o f five p g n a n c i e s was p l a n n e d a o n g single o r d i v o ed. i d o ed w o m e n . e inc e in p e r c e n t o f p r e g n a n c i e s p l a n n e d a o n g single a n d d i v o r c e d o r ido w e d w o en f r o 1971 t o 1 9 7 3 i s e n t i iy d u e t o an i n c ase in t h e te ofplanned p anciesin th et o~oups. However, the ore he! i n g a j o r i t y o f p gnancies in t h e s e t w o ~ o u p s e u n p l a n n e d . D e l i b e teiy p l a n n e d p g n a n c i e s a o n g u n a r r i e d o en, a l t l l o la t h e s e e i n c r e a s i n g , still r e p r e n t a lati ly inor p h e n o e n o n co pared to t h e c ~ t i n d high rates o f u n p l a n n e d pregnancy a o n g these w o en.

522

APRIL

1976

VOL.

13 N O .

4

CONT

CEPTION

2 Ethn~i

B y 1 9 7 3 , a b o u t laalf o f t h e p ~ g n a n c i e s in all e t h n i c g r o u p s w e p l a n n e d . In t h e e a r l i e r c o l l o r t s , C a u c a s i a n a n d J a p a n e s e w o m e n w e r e f o u n d t o b e planning a latively lligher proportion of p Naancies titan Hawaiian, Filipino and other women. Wlfiie Japan e o m e n s h o ecl n o i n c a s e in p r o p o r t i o n o f p r e ~ nancies planned over the th e yearn under study, ttleir actual p gnancy rate was t h e l o w e s t o f a n y g r o u p.. A .o n g C a. u c a s i a.n w o m e n , t i l e~ t e o f p l a n n e d p r ecg n.y..a ~....~~ .... has a i n e d s t a b l e , a n d a 2 0 p e r c e n t d e c r e a s e in tile r a t e o f u n p l a n n e d p r e g n a n c y h a s b r o u g l ~ t d o w n t h e o v e r a l l p r e g n "a n...... c y-~r a t e . In this ~oup, the increased pe ent o f p l a n n e d p r e g n a n c i e s d e f i n i t e l y r e f l ec ts i m p r o v e m e n t in a v o i d a alce- o f u n I l a n n e d p gnancy. ....

Patterns ofag~specific p: gnancy mt by etllnic groups (see Figu 2) are a clear de onstration that the cha cteristics of populations at g atest risk of unplanned p gnancy ill v a r y f r o m c l i n i c a r e a t o c l i n i c a r e a . O u t r e a c h p r o g r a m s c a n n o w e G f e c t i v e l y di c t a p p a c l i e s t o t h....e~ Sl)" e c i: population at risk by considering sucll ra ¢s. t

~

P re g n a lacy R a t es a n d S e rvi ce R te s f o r F a zIIi I y_p l a n ) f i n g_C !i T lae ....• t t a d i t i o n a l e v a l ua t i o n m e a s u r e

e/Is

f o r ~ m il y p l a n ni n g cl i n i c s is t h e cli n i"c ' s p a tie n t

1o a d , a 111e a s u r e w 1~ i c h f r c I t ~e ~ t I y ~ i Is t o t a e i ll t o a c c o u n t e i t h e r t Iae r e i a ti o il b e t w e e 1) t i e I t l o a d a d p o p t I Ia t i o zI d i s t r i b u t i o zl, o r t i i e a c t u a I ~ tl 1 i I y p I a n i I i 1!g n e e d s o f t h a t p o p u I at i o n . S ii ! c e t l 1e o bj e c t i v e o f v o I u n t a ~ f a m i I y t)i . a n. i li g .i s t o . tl a. v e~ o n l y p i a n n e d p r e g n a n c i e s , '

t h i s a n a l y s i s u s e s t h e u n p l a n n e d p r e g n a n c y r a t e as w e l l as t l e o v e r a l l 1) g n a n c y .... y i d e n t i f y g r o u p s in l e e d o f f a m i l p l a n n i n g se ices.

r a t .... t o

R a t e s o f p l a n n e d a n d u n p l a n n e d I' ~ r e- g n....a n c y, f o r t h e s t a t e p. o p .u l a t. i o n. p. r o v i d e a g e n e r a l i d e a o f t h e g r o u p s in n e e d o f ~ m ily pla n n i n g sc ~ i c e s . H o w e v e r , in o r d c r t o b e u s e fui t o ~ m i l y p l a n n i n g c l i n i c s , t h e, s e .m. . e. a"s t i r e, -s m u s t bc . . . . | a t e d m o r e d i c t l y t o t h e p o p u l a t i o n s se ed by tl e clinics. ....

T h e ra t i o n a l e f o r e s t a b Ii s tl in g a n e t w o r k o f c I i n i tli r o u gll o u t t 1i e~ s t a t e is t o i n a"k e~ s u c h s e r v i c e s a vaii a b le in e v e r y g e o g r a p h i c a r e a . A c c o r d i n g l y a n a i y si s s h o u I d p r o i d e e a c h ci i ic w i t h i n f o r m a t i o n a b o u t t h e se..... ic.... e n e e d s o f t h e p o p u l a t i o n i i v i n g in t h e s u r r o u n d i n g a r e a . Since o e n d o n o t n e c e s s a r i l y s e e k f a m i l y p l a n n i n g se. . . . . . ' c~ " eli ic n. .e. .a r e....s t t o t l m i r e s a t t 1~e h o e s , it s h o u l d b e n o t e d t h a t d i f f e r e n t i a l p g n a n c y r a t e s d o n o t n e c e s s a r i l y fleet the s u c c e s s o r fai I u re o f t h e f a m i I y p I a n n i n g c I i i c i n t I1a t a r e a , b u t, r a t 11e r, s e e t o d es c ri b e t h e m o s t c u r re n t fa m i I y p I a n n i n g b e h a vi o r a n d n e e d s o f w o m e n I iv i n g i n t h e a a. T h e a n a l y s i s is a t high rates of unplanned

~ s t e p p r o c e s s . F i ~ t , c l i n i c a r e a s in w h i c h p a r t i c u l a r g r o u p s h a v e pregnancy are identified. Second, these data a co pared with the ac tu a| tes o f se i c e b y t h e c l i n i c s t o t 11e s e ~ o u p s , t o d e t e r i n e wll e t 11e r t ! l e c l i n i c s a se i n g t h e p e o p l e l n o s t in n e e d o f s e ices.

The l a t i o n s h i p b e t e e n p l a n n i n g r a t e s a n d c l i n i c s e i c e f o r s e l e c t e d v a r i a b l e s is s h o w n in F i g u r e s 3 - 5 . E a c h f i g u s h o w s t h e c l i n i c s e ice a r e a s w i t l l higll r a t e s o f u n planned pre a h o y , a n d a l s o n o t e s w h e t h e r t h e a r e a llas a M g l l te o f clinic se ice. T h u s co parisons of need, characteristics and semite can be a d e f o r e a c h a a as f o l l o w s "

APRIL

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13

.

4

523

CONTRACE

ION

300

Legend =

~

275 250

........ . . . . . .

-

O •

#

;NF/ t

2: 2: 5 -

/ l

I

:200 17 5

-

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t} 1

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i50

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10 0 75-

0 2 5 .... 0 ...................................................................1 ................................................................................ 1....................... ::.................................................................... T ..........................................................'t .............................................................t

i5-19

20

25 .... AGES

OF

30-34 . . . .

~

40-44

WOMEN A

F/GURE 2

TERNS OF E-SP IFIC PER 1,000 . MEN R SEL (

N

PTi

COHORT

OF PR NANCl ED ETHNIC GROUPS 7)

I Gen

l R a t ~ , F i g u ~ 3 s h o w s a as witla h i g h o v e I1 r a t e s o f p r e g n a n c y , a n d those with high rates of unplanned p~gnancy.* Higll r a t e s o f p r e g n a n c y are n o t necesSarily associated with higll rates of unplanned p~gnancy, n o t e d e lier. S i x a~as have high rates of unplanned pregnancy, The family planning clinics ith high r a t e s o f s e r v i c e p e r t h o U s a n d w o in e n a g e d i 5 - 4 4 i n t !1e su ~ o u n d i n g ~ o g ~ p h i c a

* A n y area rate which was inore than five percentage points a b o ~ the rote ~ r ~ h u ~ S defined high. The OMlu rate, rather than the state rate, was used as a inean ~ r two r e ~ o n s . F i ~ t , nearly all o f the subunits, including those in tile Honolulu metropo!itan area, a ~ on ~ e island o f O ~ u . Second, the Oahu rote is slight!y lower than tile s t a t e - ~ d e rate, b e t a e the t h e e rural counties h a ~ N g h rates o f pregnancy and unplanned p r e ~ a n c y . .........

524

A P R ! L 1976

VOL. 13 NO. 4 .

.

.

.

.

.

CONTRACE

AREA I HIGHR E [ HIGHR NUMBER PR NA Y UNPLANNED PR N

ION

HIGH R CLINIC SERVICE

i 2 3 4 5 '7 8 9

i0 I1 12 13 14 15 16 17' ...

L."

K

G

8 A

S

Y

E3

AREAS WITH HIGH* R ES OF PR NAN AREAS WITH HIGH R ES OF UN ANNED P GNAN AND CLINICS WITH HIGH RATES OF $E ICE

atch in 4 o u t o f the 6 a r e , su ting t h a t c l i n i ~ are a l ~ a d y a t t e m p t i n g to m ~ t an identified need in those areas (see °Figure 3). 2.

riml S m t Rat~ of unplanned p~ o m e n also v a ~ ~ a t l y by a a. Figu of u n p l a n n e d p gnan for u n m a r r i e d for s i n g l e w o ~ e n a high in so e e o t h e r . These data clearly de o n s t ~ t e revel, t h e r than relying solely o n s t a

a n c y for b o t h arried and u n ed 4 sho s t h o s e wMch have h i g h rates or m a ~ i e d w o m e n . It is a p p a ~ n t t h a t r a t ~ , Mle~tes for ed w o m e n a ~ high in the need for analysis at the clinic s e m i t e a a w i d e figures.

When t h e clini with high t ~ o f se i c e to wo en in specific ma r ita l s t a t t~ ri a identified, the utility o f this e t h o d b e c o m e s app nt. T h e ~ is a very p o o r fit b e t w e e n t h e se ce needs o f the p o p u l a t i o n a n d clinic case loads ideally,

APRIL

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13 NO.

4

525

CONT

E

ION

AREA NUMBER ....

HIGH E UNPLANNED PR BY MARl L

HIGH R CLINIC USERS MAR! L S US S~

Y S

1 2 3

6 7 8 9 I0 11 12 i3 14

i5 16 17' U

:

B A

:

S

r

FIGURE 4

A R E A S WITH HIGH* R ES OF UNPLANNED PREGNAN AND CLINICS WI HIGH R E$ OF CLINIC USERS " MA RI L T US *

N ~

~

A

S

r

ith low service needs high c l i n i c cas e l o a d s o f a p a r t i c u l a r ° t y p e s h o u l d c o r r p o n d ill t h e p o p u l a t i o n ( a s s u m i n g t h a t t h e clinic is t h e m a j o r s u p p l i e r o f f a m i l y p l a n n i n g se ices in t h e a r e a ) . I f the clinic case l o a d c o r d is g o o d b u t t h e a ~ a still h ~ a h i g h rate o f u n p l a n n e d p gnancy, filrtller analysis sllould i m m e d i a t e l y be used on the natu Of t h e s e r ~ c e , a t t i t u d e s o f pe o n n e l , h o u r s o p e n , etc. The data also veal t h a t s o m e clinics a r e n o t y e t s e r v i n g t h e g r o u p s in t h e i r a r e a t i m t a r e m o s t in ~ e e d o f ~ m i l y p l a n n i n g se ice~ Tile r e c o m m e n d e d di c t i o n o f c l m n g e in t h e i r s e ice p r o g ms is i m m e d i a t e l y a p p a nt, a n d e v a l u a t i o n o f s u c c e s si c o n c e p t i o n c o h o r ~ w o u l d p ~ d e an o n - g o i n g m e a s u ofimpr ement. 3. A the

Figu 5 s h o w s s i m i l a r f i n d i n ~ by a g r o u p . I n s o m e are , it is e v i d e n t t h a t is a p a r t i c u l a r n e e d ~ r servic to t e e n a ~ and young adul~.

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AREA NUMBER

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S e rvi c e L eve ! a n d D i re c t i o n T h e p ceding a n a l y s i s h ~ i d e n t i f i e d a ~ a s w h e ~ ~ t e s o f u n p l a n n e d p ~ g n a n c y a h i g h a m o n g s p e c i f i e d ~ o u p s and h co pared t h e s e w i t h a r e a s w h e ~ ciinie case l o a d s t o the. s a m e g r o u ~ o f p e o p l e e high. ! n general, f a m i i y p l a n ni ng el inics in Ha waii ~ a r 0 th¢iro se ices t o the c a t e ri es o f p e o p l e ..... h o need t h e m m o s t , b u t t h e r e is g a t v a r i a t i o n In t h e ~ t e at w h i c h s e ~ i c e i s p r ~ vided. E v e r y clinic w i t h liable d a t a has its h i g h e s t ~ t e O f s e ~ i c e t o single w o m e n , w i t h divorced a n d JdoWed w o m e n second. By age, ~ e r y clinic is providing a higher rate 0 f s e ~ v i c e t o w o en u n d e r t e n t ~ f i v e .

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1

T h e fact t h a t t h e ~s of unplanned p a ~ o u p s , dest~ite t h e di e f i o n o f clinic se ice, u n d e We n o t k n o w t h e a m o u n t o f family p l a n n i n g se i s hines w i t h c l i n i c to p u the latively l o w arried women, and a m o n g wo e n r t . In 25-34, t h e high t of planned p an du the u npla nned p ~ an . . . . .

high in t h e s e a ~ a n d arital s t a t s the m a R u d e o f t h e p r o b l e m . pri te p v i d e ~ w h i c h c o t of planned pregnancy among a d d i t i o n , f o r arried w o en aged population pable of h a v i n g

Ina a8(s Figu 3 ) the ~ofpl nedp gnancies is high while se i islo This sugg ts a d i n t s o ~ o f n e e d t h a t fa ily p l a n n i n g p r o g s t also deal ~ t h ~ t h e arried w o en h o p i v e l y pi tol e f a ill d n e fly have i n a d e q u a t e spacing b e t w e e n p nanci The ty o f pr , o r i e n t a t i o n o f c!inie p e m o n n e l and app ach t h r o u g h o u t a c h t d I with th e i~u d p o t e n t i a l fa iiy p l a n n e ~ q u i t e di n t i y t h a n in ot!aer high ~ s k t ori .... The is also a t e n d e n c y f o r a n y clini t o se e 20ear-old women nside bly mo than t e e n a g e . Altho h the tes a n o t available b y s t a t u s and a ~ c o bined, t h e p nce ofhiglaer t of i in t h e 2 ~ 2 4 g u p , pl the higher te o f se ice t o single w o m e n , su ts t h a t t h e clinics are r c h i n g the relatively o l d e r single w o m e l i r a t h e r tllan ~t h e y o u n g e r ( l 5 - 1 9 yea ) s i n g l e teenage if co ct, this has t w o i plications for a r e o f i m p r o v e m e n t i n c l i n i c se c . F i ~ t , it m a y m e a n ~ l a t the o l d e r a n d o s o p h i s t i c a t e d single .. o en a a c t i v e l y seeking clinic se ic , b u t t h a t y o u n ~ r t e e n a are still i g n 0 t o f s e ice a liability o r afraid to seek se ices for fear o f p a r e n t a l involve e n t o r p u b l i c d i s a p p val. F u r t h e r outreach and a t h a n in a t t i t u d e ill b e q u i d to e c o u ~ u t i l i z a t i o n o f c l i n i e s e ic by sex u a I Iy-ac t iv e tee n age ~ . b

S e c o n d , d u t o e t h n i c and social el di n c e s in age o f f i ~ t m a r r i a ~ , single w o highersoci aged 2 0 - 2 4 are m o r-e likely to b e~ C a u sian, J a p a n e, o r C l l i n e s e a n d e c o n o m i c levels. R e a c h i n g single o m e n o f o t h e r etllnic and c u l t u I g r o u p s will q u i e x p a n d e d o u t r e a c l l p g ~ m s , p a r t i c u l a r l y ith c o n s i d e t i o n o f s cific c u i t u r a l value~

en

UMITATIONS T h e c o n c e p t i o n c o h o r t analysis u n d e r t a k e n h e r e a d d sses a d i ~ n t w a y o f : easuring family p l a n n i n g s u c c s b y e v a l u a t i n g tile p r o p o r t i o n o f c o n c e p t i o n s llich w e r e p l a n n e d d u r i n g a given t i m e period. T h e cllief ason for using c o n c e p t i o n c o h o r ~ is t h a t it~so!ves t h e p r o b l e m o f d e c i d i n g llow to i n c l u d e d a t a o n i n d u c e d a b o r t i o n s w i t h t h a t on p ancies ulting live births. Even t h o u g l l tile o r e I1 t i m a t o f u n p i a n n e d p r e g n a n c y a simi! in this a n d o t l l e r s t u d i e s in t h e U n i t e d S t a t , the conception c o h o ~ alysis p i n p o i n ~ addi tional g upswhe p~~lancy planning t a low. A d e q u a t e m e a s u r of induceda rtion, p ~ g n a n c i e s t o u n a r r i e d w o m e n , mad p ~ g n a n c y e x rience t h e beginning of sexual e x p u ~ t o t h e f i ~ t b i r t h . p r o d u c e it t h e r di ~nt Muation of p ancy planning su~ c s th t l l e u s u a l ~ m p l e su eys o f m a r r i e d w o en. Adequate e a s u s o f i n d u c e d abOrti are i p o r t a n t . It has b e e n a ~ u e d t l l a t p nancies w h i c h te ainate in i n d u c e d a b o r t i o n e i. . . . lev t since tliey d o n o t a ct p o p u l a tion growth rat~. However, induced abortions highly m l ~ ~ t the qu tion of s

u l t i m a t e fatnily size a n d d e l a y i n g t h e f i ~ t birtl!, i f this s u c c e ~ in p o p u l a t i o n li

528

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i t a t i o n is

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pri afily o b t a i n e d by t h e use o f a b o r t i o n ther than by successful p is a s t r o n g i n d i c a t i o n ' t l i a t f a ily p l a n n i n g p r s a failing.

ION

g n a n c y p l a n n i n ~ it

Adequate easu s o fp gnanci amongunma ed w o en a r e a l s o i p o r t a n L U n arried women a m o r e l i k e l y t o t e n u i n a t e an u n p l a n n e d p ancy by having an induced a b o r t i o n , a n d b o t h tile p ancy t and the absolute nu be~ ofp gnanci involving u n m a r r i e d w o m e n are s u b s t a n t i a l , a v i n g a s i d e tile c o m p l i c a t e d q u t i o n o f hether pr a f i t a l i n d u c e d a b o r t i o n is s o m e t l l i n g n e w o r .... a l w a y s p r e s e n t , c o n c e p t i o n c o h o r t a n a l y s i s a y a l s o p r o v e use ful~to f u t u national fertility studies for evaluating e in t h e r e t r spective porting of p marital p gnancies by married women. T h e a r e , o f c o u p e , l i m i t a t i o n s in t h e e t h o d . F i ~ t , it is d i f f i c u l t t o e s t a b l i s l ! t h e p per denominator for calculating planning tes. Tim n e t e c t o f t h i s l i m i t a t i o n is t o u n d e r e s t i m a t e p l a n n i n g failur . T h e m o r e w o en w h o p/an to b e c O e p g n a n t and do n o t, a n d t h e f e w e r w o na e la wt 1o a s e x u al !y a c tive, t lie m o re t h e c o n c e p t i o n cola o r t a n a i y s i s ill t m d e ~ t a t e tlie u n p l a n n e d p r e g n a n c y r a t e . A second difficulty itll t h e m e t h o d is t h e p r o b ! e c a u s e d b , s m ali n u m e r a t o ~ i f 1 cal a as ( i n o u r c a s e e have used clinic a a s ) h a v e a small n u m b e r o f e v e n ~ . While the tes a still " t r u e , " t h e y m a y b e u n liable in t h e s e n s e t h a t t h e y r e p s e n t s h o r ~ t e r m t re n d s a n d d o n o t

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b y Io o k i n g a t seve r a i c oll o r is, b u t i t w o u ! d p e r! aa p s b e b e t i e r t o i 1i cl u d e I on ge r t i m e peri o d s (e. g., six m o n t h s in s t e a d o f t w o ) in eacll c o n c e p t i o n c o l a o r t . A t h i r d d i f f i c u l t y , n o t r e s t r i c t e d t o t h i s m e t h o d , is t h a t k n o w i n g w h i c h v a r i a b l e s p d i e t p g n a n c y p l a n n i n g d o e s n o t n e c e s s a r i i y tell a p r mad inist tor wliat to do to i p ve p l a n n i n g rates. I d e n t i f y i n g g u p s w i t h l o w p r o p o r t i o n s o f p l a n n e d p r e g n a n c i d o e s ot b y i tsei f s u g ~ s t t h a t n e p r o c e d tires ill i n c r e a s e plan n i n g tes in tiaose g r o u p ~ A f o u r t h d i f f i c u l t y d e a l s witll tlle t y! p e o f d a t ~ qui r ed for the analysis u n d e r t a k e n ilere ....R e l a t i v e i y f e w p l a c e s h a v e t h e n e c e s s a r y i s o l a t i o n , h i g h p r o p o r t i o n s o f p r e g n a n c i e s b e i n g t e r m i n a t e d in h o s p i t a l s , a n d o t l e r p e c u l i a ~ t i e s t h a t a ! l o w t h i s t y p e o f a n a l y s i s . We s u s p e c t t he m e t l a o d c a n be u s e d in a r e a s o f l o w p o p u l a t i o n t u r n o v e r in t h e U n i t e d S t a t e s a n d in sucli c i t y s t a t e s as S i n g a p o r e a n d H o n g K o n g , o r in a r e a s w l l e r e r a t h e r c o p l e t e p o p u l a t i o n m o n i t o r i n g is c u r r e n t l y u n d e r ay. I t is d i f f i c u l t , 11o e v e r , t o s e e l i o the methods e h a v e u s e d c o u l d b e e x t e n d e d t o l a r ~ a as o f d e v e l o p i n g c o u n t r i e s itll inc o m pl e t e c e n s us d a t a . Nevertheless, the ne m e t h o d w e !lave p r o p o s e d f o r a ! u a t i n g s u c c e s s in p r e g n a n c y planning o rs a n i m p o r t a n t a l t e r n a t i v e t o o t h e r e t h o d s in use. T i l e m a j o r a d v a n t a g e s o f t h e n e w t e c h n i q u e a r e : tlle r e l a t i v e c u e n c y a n d c o m p l e t e n ~ s o f porting of pregnancieS, regardless of wlio experiences the and l l e t l ! e r t h e y t e r m i n a t e d in a b i r t h o r abortion; t h e t e c h n i q u e ' s s e n s i t i v i t y t o t h e i l n m e d i a t e i m p a c t o f c h a n g e s in p r e g n a n c y p! n i n g o p tions; and i~ potential for rapid feedback toan aluation of on-going family planning pr ~alllS. SUMMARY

Data e collected m o en who conceived during specified periods from I97! t h r o u g h J u n e 1 9 7 3 in o r d e r t o d e t e ~ i n e : (a) the t ..o f p l a n n e d a n d u n p l a n n e d CO11C¢~ t i o n t h r o u g h o u t t h e s t a t e , o v e r t i m e a n d b y c l i n i c se ce are ; a n d ( b ) t h e c h a ~ c t e r i s t i c s will ch a re k n o w n t o i n f l u e n e e ~ r t i l i t y b e h a v i o r ( a ~ , a r [ t a l s t a t u s , an d e t h n i c g r o u p ) o f thosewo en h o failed t o p l a n t h e i r c o n c e p f i o n s . T h e s e d a t a e r e c o p a r e d ith the cha cteristics of o e n s e r v e d b y t h e f a m i l y p l a n n i n g c l i n i c s in v a r i o u s a r e to determine hether se ces e b e i n g e x t e n d e d ~t o h i g h r i s k ~ o u p s .

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ION

During the t h r e e y e a ~ under study, the was a slight d e c l i n e in tl!e overall p r e g n a n c y rate fro ! 12~to 107 p e r t h o u s a n d w o m e n a ~ d 1 5-44. T h e .... te o f p l a n n e d p r e g n a n c y inere e d f r o ~ r t h o a n d ( C o h o r t 4 ) t o 54 p e r t h o a n d ( C o h o r t 7), wlaile t h e te o f u n p l a n n e d p r e g n a n c y was d uced fro a higll o f 6 6 p e r t h o u s a n d in i 9 7 2 ( C o h o r t 5) t o 4 9 p e r tlaousand ( C o h o r t 7 ) in 1 9 7 3 . T h e c o b i n a t i o n o f an i n c r e e in t h e te o f p l a n n e d p r e g n a n c y a n d a d e c r e a s e in t h e rall p r e g n a n c y te i n d i c a t e s p r o g r e was b e i n g a d e t o w a r d t h e p r i ary goals o f t h e fa ily p l a n n i n g p r o g . M o s t o f t h e i n c ase in p l a n n i n g was b y m a r r i e d w o en. M o s t single w o m e n w e utilizing abortion t o solve t h e p r o b l e m o f an u n p l a n n e d p g n a n c y . E v a l u a t i o n o f t h e g r o u p s in. n e e d o f se ice e a c h clinic a ~ a , a n d c o m p a r i s o n o f t tie s e fin d i n ~ wi t h t h e c h a c t e fi s ti c s o f w o e n a c t u a !!y se rye d b y t h e cli n i c, i d e n ti fi ed areas w h e se ices w e r e n o t b e i n g d i r e c t e d to g u p s in n e e d . T h e s e r e g i o n a l di nces p vided e x a m p l o f s i t u a t i o n s p o t e n t i a l l y a e n a b l e t o a p p l i c a t i o n o f e v a l u a t i o n r ults in o r d e r t o give d i r e c t i o n t o f a m i l y p l a n n i n g services. A

N

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S

T h i s p r o j e c t was s u p p o r t e d b y tlle N a t i o n a l I n s t i t u t e o f Ctfild Healtta a n d H u a n D ~ el .o. p. . . e. n. t (G ran t # 0 58 53 ) a n d t h e D e p a r t m e n t o f H e a !t h,~ S t a t e o f H a w aii. T h e au th o ~ w i s h t o t h a n k J o a n ne N a ka g a wa M i nja Ch oe a n d P e ~ y S c h w e rt feger f o r ~:esea h assis t a nce, H a w a i i p.T.i~ a n n~ e d P a r e n t h o o d f o r p r i d i n g d a t a o!1 clinic p a t i e n t s , o u r collea e Dr. R o n a l d P i o n f o r p r e s s i n g us t o t h i n k . i n t e r s o f p l a n n e d a n d u n p l a n n e d p ancies, a n d Lois Berider f o r p r e p a r i n g tile m a n cript in its finaI.fo .

V

FE

NCES

1

S t e i n h o f f , P.G., P a l m o r e , J . A . , S itll, R . G . , risky, D., a n d P i o n , R. P r e g n a n c y P l a n n i n g I~! HaWaii. F a m i l y P l a n n i n g P e ~ p e c t i v e s 7: 3 ( M a y / J u n e 1975).

2.

D i a ~ o n d , M., S t ei1111oif, P.G., Pal m o r , A., a n d S i t !1, R.G. Se x u aii ty Bi r t !I C o n t r o l a n d A b o r t i o n " A D e c i s i o n - M a k i n g S e q u e n c e . J. o f Biosocial S c i e n c e 3:347-361, (1973).

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