The Birth Control Bust : Adults in the United States are abysmal at family planning. So why are we suprised when our daughters get pregnant?

They seriously dislike contraceptives and often fail to communicate to their partnerson how to best avoid an unwanted pregnancy. And, about half of the time, their pregnancies are unwanted surprises.

And they’re not just 18 or younger.

American adults are abysmal at family planning, a little recognized fact that raises serious questions about whether sexually active teen-agers can be expected, somehow, to do any better than their adult role models.

More than 60% of women 20 to 24 say their pregnancies are unplanned, as well as 77% of women older than 40.

Even men and women in their prime childbearing years--ages 25 to 34--do a poor job of controlling their fertility, according to a new report by the government-sponsored Institute of Medicine. About 45% of their pregnancies are unintended.

“This report reframes the teen pregnancy issue,” says Dr. Helen Rodriguez-Trias, a Brookdale, Calif., pediatrician and member of the IOM committee on unintended pregnancy. “Teens are responsible for only 20% of the unintended pregnancies. That is important because the focus has been on teens as if that is the only age group in the world with this problem.”

The only difference, it appears, is that teen-agers pay mightily for their mistakes. Typically without mates, financial independence and emotional support, adolescents have less influence over the outcome of their pregnancies and suffer far greater consequences, says Dr. Felicia H. Stewart of the federal Office of Population Affairs.

“We think about this in terms of adolescents because it is such a burden for them. It makes it difficult for them to fulfill education goals and get a good start in life. And for very young women, pregnancy is a health risk. But it’s not that teens own this problem,” Stewart says.

Indeed, studies show that they are far more responsible than their collective reputation suggests.

While the rate of teen pregnancy has increased dramatically since the early 1970s because more adolescents are having sex, among sexually active adolescents only, pregnancy rates actually fell 19% between 1972 to 1990, according to a 1994 report by the Alan Guttmacher Institute.

Overall, about 20% of teen-age girls who have sex get pregnant.

This improvement is largely due to better use of contraceptives. Studies show that two-thirds of teens say they used contraceptives the first time they had sex; other research shows condom use among teen-age boys has nearly doubled in the past decade.

Despite this progress, the figures widely quoted in policy debates bemoan U.S. teen pregnancy rates as twice as high as in Canada, England and France; three times as high as in Sweden, and six times as high as the Netherlands.

Less talked about, however, is the rate of unintended pregnancy among U.S. adults compared to other developed countries: double that of Canada and Sweden and four times higher than the Netherlands.

Using numerous measures, adults appear to be poor role models for their children regarding responsible sexual behavior. In particular, studies show that American adults:

* are uncomfortable with discussing sexual issues;

* are undereducated about contraceptives and reproductive health;

* encounter many barriers in obtaining family planning services (only 20% of private insurers and 40% of HMOs cover contraceptives);

* are dissatisfied with the contraceptive choices available to them.

“In truth, avoiding unintended pregnancy can be hard to do, requiring specific skills and steady dedication over time from both partners,” state the authors of the IOM report, referring to people of all ages.

Most striking among the IOM’s findings was the level of adults’ ignorance surrounding reproductive health and contraceptives. For instance, a 1993 Gallup Poll found that more than half of American women erroneously believe that oral contraceptives pose substantial medical risks, including cancer, when in truth, oral contraceptives are one of the safest and most effective contraceptives.

In a recent study, Dr. Michael J. Rosenberg, a North Carolina researcher and consultant in Chapel Hill, N.C., found that among the 3.7 million women who begin taking oral contraceptives in a given year, 1 million become pregnant unintentionally--for the most part because they stop using the Pill because of side effects and fail to use another reliable contraceptive. These women often do not know or were not told by their doctors that side effects, such as irregular bleeding, usually disappear after a few months on the Pill.

The ignorance and myths surrounding oral contraceptives transcend all age groups, he says, adding that older teens may be no worse Pill users than their older counterparts.

“What I hear all the time is that younger women are not reliable contraceptive users. But what we found in our study was that that is only true among younger women up to age 15. After age 15, there are other predictors on whether the woman will be a good user or not,” he says, such as tolerance for side effects and whether the woman has a regular daily routine.

Moreover, adults--who are supposed to teach kids about responsible sex--are not very good teachers.

Polls show that adults overwhelmingly disapprove of teen-agers having sex, and almost all want their teens to use contraceptives if they do have sex. But parents often deal with this ambiguity by saying nothing.

“We are terribly conflicted as a society about teen sexuality, about giving them the information they need to make good decisions,” Rodriguez-Trias says. “It’s not that many people who have such good relationships with their teens that they can guide them through what is a stormy period of life.”

According to a project by the Annie E. Casey Foundation designed to improve communication between parents and children about reproductive health, the parents themselves had “major gaps in their knowledge” and needed help learning basic information.

Even a 1987 survey of middle-school sex education teachers found “clear evidence of misinformation about various methods of contraception; 77% held the erroneous belief that women taking oral contraceptives should stop from time to time ‘to give the body a rest,’ ” the IOM reported.

Sexually active adolescents face all these pressures--and then some, including:

* a lack of developmental maturity to use contraceptives effectively;

* the need to hide contraceptives from adults;

* feelings of guilt about being sexually active;

* the need to also protect themselves from sexually transmitted diseases, which depends on using condoms as well as a more reliable method to avoid pregnancy.

The issues sometimes overwhelm adolescents, who may be pressured to have sex.

Jennifer Grik of Manhattan Beach is a newlywed who has a college degree and a good job in textiles. But she still cries when she thinks of the baby boy she placed for adoption seven years ago. Unlike adults who experience an unwanted pregnancy, teen-agers often suffer lifelong consequences.

“I knew the facts. It wasn’t a matter of being uneducated about sex,” says Grik, now a volunteer counselor to pregnant teens. “It was more the pressure from him; you know, ‘If you love me, you’ll do this.’ I thought nothing bad would happen to me. It was an attitude that I didn’t consciously think about.”

Elena Webb is typical of teen-agers who try to be responsible in the face of poor odds. She felt she couldn’t consult her parents when her boyfriend asked her to have sex.

“In our house, they thought that not talking about something meant not doing it,” says Webb, now 24, of Los Angeles. “I felt when I became sexually active that I couldn’t tell them.”

Nevertheless, she found a nearby Planned Parenthood clinic in the Yellow Pages and obtained oral contraceptives. She hid the pills in a shoe box in her closet.

“I was responsible enough to know to take it every day. In some ways, I was trying to be responsible,” Webb says.

But her mother found them.

“When I got caught with them I lied and said that I wasn’t having sex,” Webb says.

One month later, she was pregnant. But, like Grik, Webb succeeded in spite of the setback. Her parents helped raise her son, Christopher, while she attended UC Riverside. She is now studying for her master’s degree in social work.

And she feels sorry for the frightened adolescent that she used to be.

“I needed someone to tell me that it is normal to be curious about sex but that you don’t have to act on it,” Webb says. “Just to be able to talk about sex and that it isn’t a bad thing. If you are a teen and you are thinking about sex, you’re considered bad, you’re wrong. But kids need to know it’s normal to think about sex.”

*

Teen-agers often show good intentions but flawed logic when assuming responsibility for sexual activity. For example, many teens rely on condoms to protect against pregnancy even though the failure rate for them ranges from 13% to 28%.

Jorge knows this personally. The 17-year-old Valley youth was trying to avoid pregnancy by using condoms, but his girlfriend got pregnant anyway. “I don’t know what happened, man,” Jorge says dejectedly. That night the condom broke and he vowed he would try another type the next time. “But there ain’t gonna be a next time because she’s pregnant. After the baby, I’m gonna try the Pills.”

Teen-agers who opt for prescription contraceptives, such as the Pill, often procrastinate too long. On average, sexually active adolescent girls wait almost one year between initiating intercourse and seeking prescription contraceptives.

“They have to decide to get contraceptives, make an appointment, keep the appointment, get the contraceptives, hide them and use them. That’s a whole lot of steps for a 14- or 15-year-old,” says Dr. Lawrence Neinstein of the Division of Adolescent Medicine at Childrens Hospital, Los Angeles.

Like adults, adolescents are not crazy about the contraceptive choices available to them. Norplant, the surgically implanted contraceptive that provides five years of protection, has been largely rejected by teen-agers who have been frightened by reports released late last year that Norplant caused severe side effects.

The contraceptive’s foundering popularity is a disappointment to family planning officials because it has great promise to help teens control fertility.

“We all had high hopes for it, and I still believe that with counseling from a provider who has experience with it, it’s still a good method,” says Margie Fites Seigle, chief executive officer of the L.A. Regional Family Planning Council. “Requests for it have plummeted; not just for teens but for all women. The question now is can we ensure it is a safe method? We know it’s effective, and we know it’s cost effective.”

In a study last year, Dr. Margaret Polaneczky of New York Hospital found that the implant was 19 times more effective than oral contraceptives in preventing pregnancy among teens.

But there is clearly more to teen pregnancy than just making contraceptives available. In one study in Baltimore, teen-agers who had a negative pregnancy test at a family planning clinic were counseled to use contraceptives, but half of the adolescents became pregnant within 18 months anyway.

“It is assumed that following such a reprieve, a young woman will be open to messages about contraceptive use, and that simply making services available at that time will be sufficient. Clearly, this is not the case,” noted the chagrined authors of the Baltimore study in the journal Family Planning Perspectives.

Indeed, it is so common for a teen-ager to have at least one clinically verified negative pregnancy test before becoming pregnant that the Los Angeles Regional Family Planning Council has implemented a Teen Retention Project to provide extra family planning counseling services at that time. The program offers young women incentives, such as gift certificates or movie tickets, to return for follow-up exams on a regular schedule.

No one expects miracles. And don’t ask teens to figure out what adults can’t.

Luana Ybarra has not figured out the intricacies of family planning, either as a teen-ager or as an adult. She first became pregnant at 18.

“We weren’t using any protection,” she says, chasing her rambunctious toddler around. “We didn’t want him. It was just dumb.”

The couple married, kicked drug habits and re-enrolled in high school. But Ybarra, 20, is pregnant again. She sighs.

“This time we used condoms, but I still got pregnant. I dunno. Maybe it’s a God thing this time.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Girls Mirror Women

Unintended pregnancies are common to all age groups. Although teens have the highest rates, women in their early 20’s and early 40’s often fail to take effective precautions, many unintended pregnancies end in abortion.

Age 15-19 Unintended Pregnacies: 81.7% Unintended Pregnacies Ending in Abortion: 81.0%

Age 20-24 Unintended Pregnacies: 60.6% Unintended Pregnacies Ending in Abortion: 51.0%

Age 25-29 Unintended Pregnacies: 45.2% Unintended Pregnacies Ending in Abortion: 47.3%

Age 30-34 Unintended Pregnacies: 42.1% Unintended Pregnacies Ending in Abortion: 50.1%

Age 35-39 Unintended Pregnacies: 55.9% Unintended Pregnacies Ending in Abortion: 55.1%

Age 40-44 Unintended Pregnacies: 76.9% Unintended Pregnacies Ending in Abortion: 59.3%

Source: J.D. Forrest, “Epidemiology of Unintended Pregnancy and Contraceptive Use,” American Journal of Obstetrics and Gynecology, 1994.

Problems with Birth Control

Teen-agers tend to use contraceptives as effectively as typical adult users. However, poor teens have numerous problems using contraceptives. Here are failure rates: Pill

Typical users (all ages): 3%

Non-poor Teens: 6%

Poor Teens: 13%

Condom

Typical users (all ages): 12%

Non-poor Teens: 13%

Poor Teens: 27%

Diaphragm

Typical users (all ages): 18%

Non-poor Teens: 21%

Poor Teens: 37%

Rhythm

Typical users (all ages): 20%

Non-poor Teens: 27%

Poor Teens: 52%

Spermicide

Typical users (all ages): 21%

Non-poor Teens: 26%

Poor Teens: 50%

Source: Studies in Family Planning, Vol. 21, No.1. Jan/Feb 1990,”Contraceptive Failure in the United States: An Update.

Unplanned Pregnancy Rates

Women of all ages fail to use contraceptives and become pregnant even when they don’t want to become pregnant. Among women who do not use contraceptives, teen-agers’ rates of unintended pregnancy are only slightly higher than women in their 20’s.

Age 15-19: 20.6% Unintended Pregnacy

Age 20-24: 20.1% Unintended Pregnacy

Age 24-29: 21.1% Unintended Pregnacy

Age 30-34: 15.2% Unintended Pregnacy

Age 35-39: 11.5% Unintended Pregnacy

Age 40-44: 11.5% Unintended Pregnacy

Source: National Center for Health Statistics

Delays Still Common

Most young women are sexually active for a substantial time before they go to a doctor or a clinic.

Made medical visit before or in same month as first intercourse: 12%

Made medical visit 1-3 months after: 11%

Made medical visit 4-6 months after: 5%

Made medical visit 7-12 months after: 12%

Made medical visit one year or more after: 29%

Made no medical visit at time of survey: 31%

Source: The Alan Guttmacher Institute, “Sex and America’s Teenagers,” 1994.

* The Series at a Glance:

Sunday: High pregnancy rates among Latinas.

Monday: The invisible fathers.

Today: America’s family planning problem.

Wednesday: The failure of sex education.