COLUMN ONE : Saying No to Birth Control : Americans can’t stem rampant unwanted pregnancies despite huge strides in science. A ‘psychic’ barrier born of taboos and guilt is blamed for failure of contraceptive ‘revolution.’

Last summer, a 27-year-old immigrant entered the Santa Ana office of Planned Parenthood, seeking the latest advance in contraception, Norplant. Her husband didn’t believe in birth control, she told the staff, and she already had six children.

They could see she was poor--and desperate. She was using a grocery bag for her purse and diluting her baby formula with water to make it stretch. She told them she needed the long-lasting contraceptive implants before her husband returned from a trip to Mexico.

The staff cautioned that her husband might notice the bandage, the bruise, the scar or the lumps of the implants. “I don’t care,” she told them after the surgery. “It’s in my arm now. It’s mine.”

The good news, according to clinic manager Michelle Tibbs: “She was feeling strong and so proud of herself for having taken care of her fertility. She knew emotionally and financially she could not handle one more child.”

The not-so-good news: “We are a community that is still just beginning to learn how to talk with our husbands, with our lovers, with our children and with our church about issues as intimate as birth control, family planning, and the spacing of our children.”

More than 30 years into the birth control “revolution” after approval of the Pill in 1960, a record 90% of sexually active American couples say they use contraceptives. Condom sales more than doubled from 1987 to 1989. Pills and IUDs are safer, and new technologies such as implants, injections, morning-after pills, condoms for women and pills for men will increase options.

And yet the practice of birth control is still shadowed with ancient taboos, male-female power struggles, embarrassment, ignorance, guilt and, not uncommonly, conception. Anywhere from 40% to 60% of all pregnancies in the United States continue to be unplanned. The number of abortions remains a constant 1.6 million a year.

Family planners who have blamed political and legal obstacles on the last two presidential administrations now see hope in the changing political winds and the surge of new contraceptive techniques.

But more pills and devices will not address one of the least studied but most formidable barriers: “psychic access” to birth control.

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At first glance, the ‘90s appear to have brought progress.

A new wave of contraceptive “hardware” is making its way into the market. According to Michael Policar, vice president for medical affairs of the Planned Parenthood Federation, it includes Norplant, the popular implant that provides hormonal contraception for up to five years; Depo Provera, an injectable progestin that lasts three to five months; three versions of the female condom, and a new generation of birth control pills with fewer side effects.

There are also a few new proposals for men: improved polyurethane condoms and the possibilities of oral contraceptives and vaccines.

The Clinton Administration is also expected to foster more reproductive options.

Bill Clinton promised during the campaign to drop the “gag rule,” instituted in the Reagan-Bush administrations, that forbids counselors in federally subsidized family planning clinics from advising patients about abortion.

In addition, family planners expect federal funds for contraceptive research, cut back during the last two administrations, to be reinstated, the FDA approval process for new products to be streamlined, and political appointees with conservative agendas to be retired from sensitive health posts. The newly designated surgeon general, Arkansas pediatrician Joycelyn Elders, for instance, has advocated making condoms available at school-based clinics.

But family planners characterize most of the advances as “baby steps.” Policar said it may take the rest of the decade to see a giant step, such as over-the-counter sale of oral contraceptives. “A woman would no longer have to see an expensive doctor or make clinic visits. She could run down to the Safeway or Lucky and pick up a supply of birth control pills,” he said.

And the new contraceptives will be undoubtedly controversial.

Family planners continue to push contraception as a logical step toward reducing not only abortions, but also, with condoms, the number of HIV transmissions. But many critics urge abstinence; they believe easy access to contraception leads to promiscuity and abortion.

The policy of Operation Rescue, the national anti-abortion organization, is “absolutely against any form of contraception that aborts a child,” said Sue Finn, California spokeswoman for the group. She said the group also opposes the contraception “mentality” because it leads to an “abortion mentality.”

“The more you encourage kids to use contraception, the more kids will have sex, the more they will not use the contraception appropriately, which results in more pregnancies and therefore results in more abortions,” she said.

“We believe that before you get married, you should abstain from sex; once you are married, if you get pregnant, you should take responsibility to raise that child,” she said. “Sex is for people who are ready and willing to take a lifetime responsibility for the outcome of sex.”

Family planners, too, prefer that youngsters delay sexual activity. Programs that teach skills beyond “just say no” have succeeded in helping inexperienced teen-agers postpone intercourse. But abstinence programs backfire if they instill shame, and can result in unprotected sex to save a reputation, according to Debra Haffner, executive director of Sex Information and Education Council of the United States.

While Haffner agrees that sexually inexperienced teen-agers need support, so, she says, do the majority of American teen-agers who are already sexually active.

For teen-agers as well as adults, “Technology alone is not going to be the answer,” said Constance A. Nathanson, director of the Hopkins Population Center at Johns Hopkins University in Baltimore. Not only must birth control be affordable and accessible, she said, “you have to have people who are prepared to use it and want to use it and are in relationships in which it’s possible for them to use it, and in a culture and a society where it’s acceptable for them to use it.”

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First of all, for birth control to work, people must be motivated to use it effectively. Of the nation’s annual 3.5 million unplanned pregnancies, nearly half result from inconsistent or incorrect use of contraceptives, the rest from using no birth control at all, according to the Alan Guttmacher Institute, a contraceptive research organization.

Studies of contraceptive use often focus on teen-agers. But some researchers suspect adults are not much different in how they view and prepare to use birth control. It may be one reason so many adults choose to be sterilized--the most popular form of contraception in the country. (Many however, say they regret it, and sterilization does not protect from sexually transmitted diseases.)

According to various studies, teen-agers often say the reason they do not use contraception is that they did not plan on having sex. Teen-agers--and others--often mean to say no, but end up saying yes; they mean to use contraception, but then they don’t.

One junior at an Ivy League college said that when his male friends don’t use condoms, it’s usually because they are too intoxicated to think about it. “Basically, it’s just a hassle to go through all this stuff, especially after a few drinks.”

“When people are drinking and start having sex, the woman most likely will say something about using withdrawal. The guy can act on it or he doesn’t. They’re counting on the responsibility of a drunk man, basically.”

Theorists speculate that people who don’t use contraception are similar to those who don’t wear seat belts, or won’t quit smoking: They don’t perceive the long-term “benefits” of avoiding disease or pregnancy as clearly as the short term “costs” of reduced spontaneity and pleasure.

Others do not use birth control because they want to control their partner. Some researchers suspect that some so-called “unintended” pregnancies are not really inadvertent. some men still want to prove their manhood; some women still want to force a marriage.

A 21-year-old woman from South-Central Los Angeles said she didn’t use birth control because she hoped having a baby would motivate her boyfriend to marry her. “He wanted to break up with me. I thought if I get pregnant and everything, he’ll stay with me,” she said.

“So I ended up getting pregnant and we ended up breaking up anyway.”

Now the mother of a 4-year-old, she said she insists on using condoms with men she dates. “I found out the hard way,” she said.

Studies have linked lack of contraceptive use among girls to low income, low aspirations and low educational achievement. They tend to have low self-esteem and feel fatalistic, powerless and alienated. “If they perceive their lives are so bleak, it doesn’t really make a difference whether they have a child or not,” said UC Davis sociology researcher Carole Joffe. “Obviously, people with life plans have more motivation to control their fertility.”

In Baltimore, health officials were alarmed at the large number of teen-agers giving birth this year. Nearly a quarter of the city’s births were to teen-age girls, one of the highest rates in the country. As a result, they offered to give them Norplant through school clinics. It is not yet known how many will accept the offer.

One 19-year-old Baltimore student explained to a reporter why she had a second child: the first “had gotten so big and I felt like she didn’t need me, she’s so independent.”

“No birth control is going to fix that,” said Susan Newcomer, a demographer with the National Institute for Child Health and Human Development. “If a girl is thinking that way, she is not going to get Norplant.”

Those who do choose Norplant may find themselves with additional problems, Joffe said. While Norplant enthusiasts envision freedom from pill-taking or negotiation with men about birth control during the heat of passion, others note the implants do not guard against sexually transmitted diseases and wonder whether the visible lumps of the implant may make young women vulnerable to a reputation of promiscuity. Some girls may feel as if they are “branded with a scarlet letter,” Joffe said.

East Los Angeles Planned Parenthood outreach worker Melinda Cordero said many young women believe that using the pill will give them a bad reputation. “It’s different from a condom. You’re taking it every day so you must be sleeping around with a lot of people.”

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Many counselors now believe that for birth control to work, women need to be in stable relationships with men who support contraception.

“There’s been a real profound change in thinking with respect to birth control,” said Joffe. The revolution promised by the Pill has failed to “inoculate” the public against the problem of unwanted pregnancies, she said. “The real revolution has been the recognition among some, not all, that birth control involves social relations, not just medical ones.”

In her research, Joffe said, “We hear again and again, ‘My boyfriend said he’d use condoms but he didn’t like them.’ The guy didn’t like them.”

In general, many women do not insist when their partners object to condoms, said UC Berkeley public health professor Gary Stewart. This happens, even though among heterosexuals, woman are more vulnerable to HIV than men.

Gayle Nathanson, executive director of the Southern California Youth and Family Center in Inglewood, said young men and young women in her center hold vastly different views about relationships and birth control. Young men link their responsibility to use contraception to whether their partner is a girlfriend (who deserves self-sacrifice) or an acquaintance (who is on her own). One problem is that “girls think they have boyfriends. Boys think they have acquaintances.”

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For birth control to work, people need to believe that the larger culture and society approve, researchers say.

In last year’s movie “Frankie and Johnny,” two lonely people are about to make love for the first time. Frankie asks her new boyfriend if he brought a condom. He says, no, you’d think I didn’t respect you. Horribly embarrassed, she tells him he can find one in her medicine cabinet.

Paradoxically, the least sexually active people are also the least likely to use effective birth control. “For them to bring a condom, to bring a diaphragm is an admission they are sexual,” Joffe said. “We live in a society where adults are incredibly embarrassed and conflicted about their right to be sexual.”

Clinic manager Tibbs said first-time visitors to the clinic are often girls who have not used contraception and are afraid they are pregnant. “I say, ‘You’re so relieved by the news of this negative test, yet you’re not protecting yourself. Have you spoken with your partner?’ They say, ‘Oh no, I could never do that.’ For the teens it’s a standard answer: ‘I couldn’t talk to my boyfriend about birth control. I’d be too embarrassed.’ ”

Contrary to the blatantly erotic images on MTV or Guess and Calvin Klein advertisements, “We still have the legacy of Victorianism, the ideology of the innocent girl in which young women are supposed to be innocent, unknowing and unknowledgeable,” said Constance Nathanson. “The power of the myth Sleeping Beauty is you don’t have any sexual feelings, you’re asleep until the guy you marry kisses you. I don’t think anybody believes it, but we haven’t constructed an alternative, positive view of sexuality for young women.”

Studies by the Alan Guttmacher Institute show that American society’s mixed messages play a major role in poor contraceptive use among teen-agers. Moralistic attitudes in society “contribute to making it harder for a young woman to be a careful contraceptor if she is led to believe that the fact she uses contraception shows she’s inviting sex or being promiscuous,” Nathanson said.

While extramarital sex is commonplace on television, most networks have chosen not to advertise contraceptives for either pregnancy or AIDS prevention, said Jennifer Daves, director of the Los Angeles-based Media Project of the Center for Population Options, which acts as consultant to producers and scriptwriters.

After Magic Johnson’s announcement that he was infected with HIV, only the Fox network agreed to advertise condoms, but only as a means of disease prevention, and then aired only one or two spots, Daves said.

Roberta Synal, media relations coordinator for the Planned Parenthood Federation of America, said the biggest obstacle to the group’s current efforts to promote birth control “is the movement to keep quiet about sex when it is being promoted in very seductive ways on TV shows, movies and advertising.”

“We always refer to what it’s like in Scandinavia where there is no stigma attached to sexuality and people use birth control. They manage to keep from getting pregnant and protect themselves from sexually transmitted diseases.”

In a 1986 analysis of teen-age pregnancy in five industrialized countries, including the United States, investigators sponsored by the Alan Guttmacher Institute found the lowest rates in the Netherlands, followed by Sweden. The United States rated the highest.

In each of the other countries, populations are smaller than in the United States and governments provide more wide-ranging social and welfare benefits. In addition, the United States experiences the greatest opposition to contraception from conservative religious groups.

Sweden’s lower teen-age pregnancy rate is credited to extensive sex education and contraception programs in the public schools. In the Netherlands, a society that has undergone rapid secularization in the past 20 years, the media is credited with breaking down taboos on talking about sex through a series of educational television programs. Dutch youngsters who can’t turn to their parents or family doctor are served by a network of family planning clinics. In addition, the Pill is widely used in the Netherlands. The study concluded that Americans, encouraged by feminists, have overestimated the dangers of the Pill.

There are signs, however, that Americans are facing contraceptive issues more openly.

While the specter of AIDS may not have changed behavior dramatically among heterosexuals, it has undeniably opened up communication about responsible sexual behavior, experts say.

“For years, pregnancy prevention workers could not get into the schools,” Joffe said. “When AIDS came along, we’re not just talking about girls getting pregnant, we’re talking about kids dying. Now there’s more open talk in schools and among parents.”

Television shows featuring realistic discussion of birth control have been increasing. This year, for instance, Roseanne talked to her daughter about birth control and the characters of “Beverly Hills 90210” discussed condoms on campus as well as virginity.

Americans have come a long way regarding openness on sexual matters, but progress is difficult in a country “hooked on making people feel guilty for being sexual,” Planned Parenthood’s Synal said.

“We’ve been with our heads in the sand,” she said. “Now we’re trying to pull our heads out.”

Thursday in View: Some couples are taking a second look at the once-derided rhythm method. And in East Los Angeles, Planned Parenthood is taking a novel approach to promoting birth control: Tupperware-style parties.

Friday in Business: Makers of the newest birth control methods are increasingly advertising directly to consumers.

Contraceptive Facts and Figures

THE METHODS

Sterilization is the most prevalent form of contraception worldwide and the United States. Here is a breakdown of the methods practiced by the estimated 35 million Americans who use contraception.

Method: Percentage of Users Sterilization*: 39.2% Pill: 30.7% Condom: 14.6% Diaphragm: 5.7% Periodic abstinence: 2.3% Withdrawal: 2.2% IUD: 2% Spermicide: 1.8% Sponge: 1.1% Other: 0.4% * Includes tubal sterilization and vasectomies

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THE FAILURE RATES

Here are the estimated percentages of U.S. women who experience an unintended pregnancy in the first year of contraceptive use. Perfect use reflects the failure rate when the method is used correctly every time.

Method Perfect Average Use Use * Implant .04% 0.5% * Vasectomy 0.1% 0.2% * Tubal sterilization 0.2% 0.5% * Hormone shot 0.3% 0.4% * IUD 0.8% 4% * Pill 1% 6% * Condom 2% 16% * Diaphragm 6% 18% * Cervical Cap 6% 18% * Periodic abstinence 9% 19% * Withdrawal 4% 24% * Sponge 8% 24% * Spermicide 3% 30% * No method 85% 85%

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THE TRENDS

Trends observed in the United States during the 1980s among women who used some form of contraception:

* Sterilization: Female sterilization increased from 23% to 28%.

* The Pill: Use increased from 28% to 31%.

* Condoms: Overall use increased somewhat, from 12% to 15%, although use increased sharply among teen-agers (from 21% to 33%) and among unmarried women (from 12% to 20%.) The rise among younger women, unmarried women and those who intend to have children may be attributable to their increased concern about sexually transmitted diseases, particularly AIDS.

* Diaphragms: Use declined only slightly, from 8% to 6%. However, there was a sharp decline in use among unmarried women and women under 30.

* IUDs: Use declined overall, from 7% to 2%.

NOTE: Figures are for 1988

SOURCE: The Alan Guttmacher Institute