FAMILY PLANNING.

Family planning refers to the use of modern contraception and other methods of birth control to regulate the number, timing, and spacing of human births. It allows parents, particularly mothers, to plan their lives without being overly subject to sexual and social imperatives. However, family planning is not seen by all as a humane or necessary intervention. It is an arena of contestation within broader social and political conflicts involving religious and cultural injunctions, patriarchal subordination of women, social-class formation, and global political and economic relations.

Attempts to control human reproduction is not entirely a modern phenomenon. Throughout history, human beings have engaged in both pro-and antinatalist practices directed at enhancing social welfare. In many foraging and agricultural societies a variety of methods such as prolonged breast-feeding were used to space births and maintain an equilibrium between resources and population size. But in hierarchical societies, population regulation practices did not bring equivalent or beneficial results to everyone. Anthropologists Marvin Harris and Eric Ross have shown that "As power differentials increase, the upper and lower strata may, in fact, develop different or even antagonistic systems of population regulation" (p. 19).

Being uniquely endowed with the capacity for reproduction, women of course have borne the costs of pregnancy, birth, and lactation, as well as abortion and other stressful methods of reproductive regulation. Social-class dominance over reproduction often takes place through the control of lower-class women by upper-class men. The particular forms these controls take vary across historical periods and cultures. In feudal agricultural and "plantation economies" experiencing labor shortages and short life expectancies, for example, there has been great pressure on women to bear as many children as possible.

In the modern era of industrial capitalist development, conservative fundamentalist groups have tended to oppose abortion and reproductive choice for women on grounds of religion and tradition. They believe that abortion and contraception are inimical to the biological role of women as mothers and to the maintenance of male-dominant familial and community arrangements. In both the industrialized north and the poor countries of the south, religious fundamentalists oppose abortion and the expansion of reproductive choices for women, and sometimes they do so violently, as in the attacks in the United States against clinics and doctors providing legal abortions. The rapid spread of evangelical Christianity and militant Islam around the world further aggravate the situation.

Partly as a result of religious fundamentalist opposition, in the early twenty-first century abortion remains illegal in many countries. It is estimated that worldwide approximately 200,000 women die annually due to complications from illegal abortions. The actual figures may be higher, since only about half the countries in the world report maternal mortality statistics. Indeed, the unchallenged position of the Vatican against artificial conception and the U.S. government policy against funding for international abortions has led some to believe that illegal abortions and maternal mortality could further increase. Not only does the Bush administration refuse money for abortions, but it also prohibits medical professionals in international organizations such as International Planned Parenthood from talking about abortion if they receive U.S. government support. In the context of both the conservative religious backlash and the problems attributed to global population expansion, family planning seems an enlightened and progressive endeavor. Yet, the movement to provide modern contraception has been fraught with gender, race, and class inequalities and health and ethical problems from the outset. Efforts to reform and democratize international family planning must necessarily grapple with these concerns.

Origin and Evolution of Family Planning

The idea of modern population control is attributed to Thomas Malthus (1766–1834), who in 1798 articulated his doctrine attributing virtually all major social and environmental problems to population expansion associated with the industrial revolution. However, as a clergyman turned economist, Malthus was opposed to artificial methods of fertility control. He advocated abstinence and letting nature take its toll and allowing the poor to die.

In contrast, birth control emerged as a radical social movement led by socialists and feminists in the early twentieth century in the United States. The anarchist Emma Goldman (1869–1940) promoted birth control not only as a woman's right and worker's right, but also as a means to sexual freedom outside of conventional marriage. But soon birth control became increasingly medicalized and associated with science and corporate control as well as with the control of reproduction within marriage and conventional family life. As the radicals lost their leadership of the birth control movement to professional experts, mostly male doctors, by the 1920s birth control, which refers to voluntary and individual choice in control of reproduction, became aligned with population control, that is, a political movement by dominant groups to control the reproduction of socially subordinate groups.

During the influx of new immigrants in the 1920s and 1930s and during the depression, when the ranks of the unemployed were swelling, eugenicist (hereditary improvement) ideology and programs for immigration control and social engineering gained much ground in the United States. Even the birth-control pioneer Margaret Sanger (1879–1966) and suffragists such as Julia Ward Howe (1819–1910) and Ida Husted Harper (1851–1931) surrendered to ruling-class interests and eugenics, calling for birth control among the poor, blacks, and immigrants as a means of counteracting the declining birth rates of native-born whites. Influenced by eugenicist thinking, twenty-six states in the United States passed compulsory sterilization laws, and thousands of persons—mostly poor and black—deemed "unfit" were prevented from reproducing. By the 1940s, eugenicist and birth-control interests in the United States were so thoroughly intertwined that they became virtually indistinguishable. In the post–World War II era, compulsory sterilization became widespread in the so-called Third World where the birth rates have been higher than in the industrialized countries (in 1995, fertility per woman was 1.9 in the more developed regions and 3.6 in the less developed regions).

In the late twentieth century, the fear of demographic imbalance again seemed to be producing differential family-planning policies for the global north and the south. This was evident in corporate-scientific development of stronger contraceptives largely for poor women of color in the south and new reproductive technologies for fertility enhancement largely for white upper-class women in the north. Some insurance companies in the United States continue to refuse to cover conception in the early twenty-first century. Countries concerned with population "implosion" in the north such as Sweden, France, and Japan are pursuing pronatalist policies encouraging women to have more children while at the same time pursuing antinatalist policies encouraging women in the south to have fewer children.

Family Planning in the Global South

Given the massive increase in population in the south hemisphere countries since World War II, much of global family-planning efforts have been directed toward those poor countries of the so-called Third World. The followers of Malthus, the neo-Malthusians, have extended his thinking, blaming global poverty, political insecurity, and environmental degradation on the "population explosion" and calling for population control as the primary solution to these problems. Their efforts have helped turn family planning into a vast establishment of governmental and nongovernmental organizations with financial, technological, and ideological power emanating from the capitals in the north toward the remote corners of the south. Within countries in the south, the hierarchical family-planning model spreads from professional elites in the cities to the poorest men and women in the villages. In India alone, there are an estimated 250,000 family-planning workers. Every year vast amounts of money are spent to promote "contraceptive acceptance" among the poor populations in the world. Contraceptive use in the "developing world" has increased from less than 10 percent of couples of reproductive age in the 1960s to more than 50 percent (42 percent excluding China) in the 1990s. The rapidly falling birth rates in the Third World are generally attributed to the "family-planning revolution" represented by expanding use of modern contraceptives.

The International Conference on Population and Development (ICPD), held in Cairo in 1994, is generally considered to have ushered in a new approach to population and development, upholding reproductive health and rights of women over meeting numerical goals for reducing fertility and population growth. Departing from earlier positions and upholding voluntary choice in family size, the ICPD Programme of Action states that demographic goals in the form of targets and quotas for the recruitment of clients should not be imposed on family-planning providers and expresses disapproval of the use of incentives and disincentives. It acknowledges the setting of demographic goals as a legitimate subject of state development strategies to be "defined in terms of unmet needs for [family-planning] information and services" (United Nations, 1994). But, as human rights activists concerned with continued abuses in family-planning programs point out, there is still a long way to go in establishing policies and ethical standards to ensure that the new health and women's rights objectives are achieved.

Notwithstanding massive spending and extensive family-planning promotion over three decades, many poor people in the Third World remain reluctant to use modern contraception in the early twenty-first century. Attitudes and the need for children among the poor are often quite different from that of family-planning enthusiasts, who are mostly middle-class professionals. Even when poor people use modern contraceptives, their continuation rates are often low due to lack of access to health care, side-effects of contraceptives, and other reasons. Given these realities and the urgency to reduce fertility, international family planning continues to rely on the use of economic incentives and disincentives as well as highly effective, provider-controlled, female methods.

Although male sterilization (vasectomy) is a much simpler operation than female sterilization (tubectomy), female sterilization is the most favored method of family planners and the most widely used method of fertility control in the world. Tubectomy is more common than vasectomy because the men in many areas refuse to have vasectomies, leaving the women little choice if they don't want more children. Female sterilization constituted about 33 percent and male sterilization 12 percent of all contraceptive use in the developing countries at the end of the 1980s. In terms of the numbers, sterilization is an increasing success, and for many women and men in the north and the south, sterilization represents a choice to be free of biological reproduction. But closer examination of conditions under which most women consent to be sterilized shows that sterilization abuse continues to be a pervasive problem for poor women.

Poverty and adverse social conditions—including lack of information and access to other methods of birth control, threats of discontinued social benefits, and economic constraints—set the conditions for abuses in family-planning programs. Targets and economic incentives/disincentives have defined the operation of many Third World family-planning programs from their inception. They have also been associated with programs directed at poor communities of color in the United States. In the early 2000s a nonprofit organization known as C.R.A.C.K. (Children Requiring A Caring Kommunity) promised a cash incentive of $200 to drug-addicted women upon verification that they had been sterilized or were using a long-term birth control method such as Norplant, Depo-Provera, or an IUD (American Public Health Association).

While targets and incentives in other realms of social policy are not necessarily wrong, the pressure to meet targets and the offer of economic incentives in family-planning programs have resulted in a highly techno-bureaucratic and monetarist approach obsessed with numbers of acceptors and financial rewards. Within such a quantitative approach, the complex psychological, sociocultural dimensions of sexuality and reproduction are easily overlooked. Not only do poor people lack much relevant information, but also, in many cases, the desperation of poverty drives them to accept contraception or sterilization in return for payments in cash or kind. In such situations, choice simply does not exist. Direct force has reportedly been used in population-control efforts in some countries, including China, India, Bangladesh, and Indonesia. But coercion does not pertain simply to the outright use of force. More subtle forms of coercion arise when individual reproductive decisions are tied to sources of survival, like the availability of food, shelter, employment, education, health care, and so on.

The "Second Contraceptive Revolution"

Claiming that the earlier contraceptive revolution was a major success, the international family-planning establishment declared the launching of a "second contraceptive revolution" and a "contraceptive 21 agenda" for the twenty-first century. This, like the earlier phase, upheld the biomedical model of mass female fertility management. In 2004 about ninety-four new contraceptive products were being pursued, of which many were variants of existing methods. Among these were four IUDs, seven hormonal implants, five hormonal injectables, five hormonal pills, six vaccines, and six methods for female sterilization.

The second contraceptive revolution also envisaged a greater role for private industry. Given the "latent demand" for new contraceptives, liberalization of trade, privatization of state-run enterprises, and other factors, contraceptive marketing in the Third World promised to be even more profitable for pharmaceutical companies than they had been in the past. The privatization of health sectors, increasing corporate mergers (such as the merger of Pharmacia Sweden and Upjohn of the United States), and the extension of intensive contraceptive promotional and marketing strategies further augmented the power and profits of transnational pharmaceutical companies in the south.

The United States Food and Drug Administration (USFDA) in the early 2000s was completely exempting more and more drugs and medical devices from review before marketing, a move that could have detrimental repercussions across the world. The ICPD and its "new" reproductive-rights agenda, however, did not address the need for strict guidelines to monitor contraceptive trials and the marketing practices of corporations. Calls for population stabilization in the context of GATT (General Agreement on Trade and Tariffs) and other "free trade" agreements, could result in further easing of protocols for contraceptive trials. Feminist activists fear increased corporate dumping of dangerous and experimental contraceptives on the bodies of poor women. Their concerns are based on the history of experimentation of contraceptives such as Depo-Provera and Norplant on poor women in the north and the south without informed consent, the use in the Third World of the Dalkon Shield IUD and other contraceptive devices banned in the United States, and other unethical and dangerous practices. The FDA has, however, been stalling on making emergency contraception available over the counter, maintaining that it needs further testing. Planned Parenthood, NOW, and NARAL, among other feminist organizations, have long urged the approval of the drug.

Health and Human Rights of Women

Modern family-planning programs have provided many poor women with contraceptives and the ability to limit family size; but they have rarely given women genuine choice, control over their bodies, or a sense of self empowerment. The focus of family planning has been on population stabilization and the meeting of targets rather than on the means or the processes to achieve its ends. Although many family planners in the early 2000s call for women's reproductive rights, population-control programs seem to be moving in authoritarian directions.

Article 16 of the Teheran Proclamation issued by the United Nations Conference on Human Rights in 1968 states that "Parents have a basic human right to determine freely and responsibly the number and spacing of their children" (United Nations, 1974). This Article represented a major victory for the population-control movement. Perhaps the term "responsibly" was the real victory because it can be interpreted in a more-or-less coercive way. Indeed, the overwhelming importance given by international donors and local governments to fertility control has led to a relative neglect of other aspects of family planning and reproductive and human rights such as the right of the poor to health and well-being, including the right to bear and sustain children. Indeed, the neglect of the survival issues by the family planners has allowed right-wing fundamentalists to appear as the only ones concerned with family and community.

The emphasis on family planning has undermined public health care and Maternal and Child Health (MCH) in many countries. In 2004, many of the new hormonal and immunological contraceptives did not protect against HIV/AIDS. In many poor communities in Africa ridden with AIDS, modern contraception was widely available while pharmaceutical drugs for AIDS were not. Target pressure and incentives continued to drive interests of health-care personnel toward population control over provision of health care. Population agencies spoke in public of integrating family planning within a broader health-care framework. But in private some have argued that family-planning programs should not be "held hostage" to strict health requirements and that maximum access to contraceptives should override safety and ethical concerns. Even when the population-control organizations have taken efforts to address public-health issues and women's social and economic rights, the population-control objective has continued to be dominant. The Safe Motherhood Initiative is an example.

The Safe Motherhood Initiative was launched by the World Bank, United Nations Development Program, United Nations Children's Fund (UNICEF), United Nations Fund for Population Activities (UNFPA) and the World Health Organization (WHO) to reduce maternal mortality. In many cases, this initiative has aimed simply to reduce childbearing; the assumption being that fewer births will cause fewer maternal deaths. A 1992 World Bank evaluation of its population-sector work admitted that its foray into broader health initiatives had been motivated by the "political sensitivity" of population control and the need to dissipate Third World perception that "population control is really the Bank's strategic objective." The report further notes that many countries that would not accept donor support for population control would nevertheless "accept support for family health and welfare programs with family planning components" and that the likelihood of family planning getting "lost in an MCH program" was less because MCH was better accepted as a "legitimate intervention for both health and demographic reasons" (World Bank, 1992).

As Indian health researcher Malini Karkal has pointed out, the tendency to attribute maternal mortality simply to pregnancy and childbirth by the Safe Motherhood Initiative and other such programs has led to a relative neglect of causes of reproductive mortality that supercede maternal mortality. Deaths due to unsafe sterilization, hazardous contraceptives, deaths associated with sexually transmitted diseases, cancer of the reproductive organs, and unsafe treatment of infertility also account for a large proportion of reproductive mortality. Where births have been "averted" due to family-planning programs, the reproductive choices or conditions of women or of the general population, for that matter, have not increased as a result. In India, although birth rates have declined, infant mortality at about 72 per 1,000 births and maternal mortality at about 460 per 100,000 live births in 1995 continued to be relatively high. As women's-rights advocates argue, improvement of the status of women is not the consequence of family-planning programs as believed by the population planners. Rather it is a more complex outcome resulting from rise of age in marriage, education, employment, better living conditions, and general awareness, as well as family planning. Indeed, everywhere, voluntary acceptance of contraception seems to be correlated with women's access to education.

Phenomenon of "Missing Women"

In the 1980s and 1990s in several Asian countries, the proportion of girls born and living appeared to be steadily decreasing. In India, the ratio of women to men was 929 females to 1,000 males, whereas in 1901 it was 972. In China after the one-child family policy was implemented in 1979, the sex ratio became more skewed. There were 94.1 women per 100 males in the 1982 census; in the 1990 census, there were only 93.8 females per 100 males. Demographic data shows that in the early 2000s in China, India, Pakistan, Bangladesh, Nepal, West Asia, and Egypt, 100 million or more women were unaccounted for by official statistics. Further skewing of sex ratios particularly in the world's two most populous countries, India and China, are likely to create serious demographic and gender issues in the future.

One factor contributing to the problem of "missing women" is sex-selective abortions. New technologies such as amniocentesis, ultrasound, and chorionic biopsy, developed for purposes of prenatal testing for birth defects, are increasingly used for the purpose of sex determination. Sex-selection procedures are increasingly advertised in the United States as scientific advances intended to improve choice in family planning and they are likely to become routine procedures. In the patriarchal societies of China and India, where the preference for male children and the pressures to reduce family size are both very strong, abortions of female fetuses seem to be widespread. Although the use of technologies for sex selection is illegal in China, they are readily available even in rural areas. With a small bribe, parents can easily find out the sex of the embryo and abort it if it is female, thus ensuring that the only child allowed by the State's one-child-family law be a male.

In India too, sex-selective abortion is a thriving business. According to some estimates, between 1978 and 1983 alone, 78,000 female fetuses were aborted after sex-determination tests. Researchers have found that some poor districts in Uttar Pradesh, Maharashtra, and Gujarat, which do not have basic services such as potable water and electricity, have clinics doing a flourishing business in prenatal diagnostic techniques for sex selection. Even poor farmers and landless laborers were willing to pay 25 percent compound interest on loans borrowed to pay for those tests. Given extreme social pressures to produce sons, many women, not only poor uneducated women, but also educated urban women are resorting to abortion of female fetuses. Some middle-class Indian women justify these actions on grounds of choice, and some medical doctors and intellectuals have also argued that it would prevent the suffering of women and that in the long run the shortage of women would lead to their improved status in society. Nurses seeking to meet their family-planning targets actively encourage "scanning" for sex determination and abortion of female fetuses. Some doctors also promote sex-selective abortion as an effective method of population control that would allow the Indian government to achieve its population-control targets.

Female infanticide and underreporting of girls are other factors contributing to the "missing women" phenomenon. The Chinese government has either denied or condemned the practice of female infanticide, but reliable data are not available. Female infanticide does have a long tradition in patriarchal societies such as China and India. But as the demographer Terrence Hull has noted, the "behavioral and emotional setting of infanticide in contemporary China" tends to be substantially different from the traditional pattern (Hull p. 73). The resurgence of infanticide since the early 1980s, is at least partly related to the pressures of the Chinese family-planning program, and the infants killed at birth have been overwhelmingly female. Most of the abandoned infants who end up in state-run orphanages are girls. Many of these girls, as well as boys, are subjected to starvation, torture, and sexual assault. Women's rights activist Viji Srinivasan, who has studied female infanticide among poor communities in Tamil Nadu, India, has also identified the "internalization of the small family norm" due to family-planning promotion as a source of female infanticide (pp. 53–56). Her study raises questions about the ethics of aggressive population control in highly patriarchal societies and underscores the need for economic empowerment and elevation of women's status.

Family Planning and Authoritarianism

Family-planning advocates and organizations claim that the modern "contraceptive revolution" has been achieved without coercion, through "purely voluntary means" with only "minor disadvantages" to people in the Third World (UNFPA). But a closer examination of the methods of contraception and strategies of family planning reveals widespread human-rights violations and safety and ethical problems. In this regard, it is well to remember the arguments commonly put forward by influential neo-Malthusian demographers, according to whom political will and strong measures need to be used in the fight against population growth, and democratic norms may have to be sacrificed for the sake of the greater good.

Some analysts argue that neo-Malthusian family planning is a quantitative, technical, and bureaucratic approach driven by urgency and aggression to reduce the numbers of the human population in a race against the mechanical clock. Controlled by money and political influence, it has erected a vast global family-planning enterprise far removed from the broader economic needs and cultural interests of the masses whose numbers it seeks to control. Such a hierarchical and at times violent approach can reinforce existing psychosocial structures of domination and subordination; men over women (patriarchy); capital over labor (capitalism); north over south (imperialism); white over people of color (white supremacy/racism); and so on.

Dualistic thinking, the separation of self and other and of subject and object, lies at the root of neo-Malthusianism. As such, it is unable to comprehend the inherent connectedness between the self and the other. Fear of the unknown and desire for permanence and control, in this case, the control of the global masses and their reproduction, underlies this dichotomous thinking. As a fragmented, top-down, and homogeneous approach, Malthusianism leaves no room for more balanced, qualitatively oriented participatory and diverse approaches, for example, indigenous peoples' and women's approaches to reproduction. Aggression and conquest rather than compassion and caring drive the population-control establishment and the larger model of technological-capitalist development that it represents.

Indeed, understanding and empathy require patience; but, according to its advocates, population control is urgent; it cannot lose time. Thus, terminal and high-tech methods are seen as being quicker, easier, and more efficient to administer than women-controlled methods of fertility control. However, myopic vision arising out of self-interest and fear leads to dangerous policies of gender, race, and class oppression. If unchallenged and unchecked, neo-Malthusian family planning could become an even greater tool of authoritarianism and social engineering in the future than it has been in the past. A shift from population control to birth control, from external domination to greater individual control over reproduction, can only be achieved through fundamental transformation of the global political-economic order and the dominant ideologies of both religious fundamentalism and neo-Malthusianism.

Reproduction is a highly political issue and it is unlikely that in the long term either the problem of population stabilization or the global social crisis will be resolved by political repression or high technology. Questions pertaining to democracy and authoritarianism are embedded in the structures of the society. Widespread protests against forced sterilizations in India under the Emergency imposed by Indira Gandhi were a major factor in her defeat in the subsequent elections. Field researchers who have observed grassroots reactions to coercive population-control policies in India have warned that mounting dissatisfaction could again lead to conflict and violence as it did under the Emergency.

In China too, despite state authoritarianism, there have been outbursts and protests against family-planning policies, and the government has had to soften its policies on a number of occasions. Reporters who have traveled in the Chinese countryside have observed that the government's population policy has caused "a mixture of anger, support, frustration, enthusiasm, deviousness and pain" and that the "desire to procreate" stirs more emotion than any desire for political democracy (cited in Bandarage, 1997, p. 102).

Toward Democratic Reproductive Rights

A democratic and sustainable approach to human reproduction must incorporate social, ethical, and ecological criteria avoiding the dogmatism and extremism of both pronatalist right-wing religious fundamentalism and antinatalist neo-Malthusian family planning. Appropriate technology and democratic social relations must define the realm of human biological reproduction as they must the realm of economic production. Numerical targets and economic incentives must be abolished from family-planning programs in the south and they must not be extended to the north. Quality health-care services and a range of safe contraceptives that help protect people against STDS and HIV/AIDS are required. Development of safe male contraceptives is essential for greater male-female partnership in birth control and family planning. Abortion should not be used as a contraceptive method, but safe and legal abortions should be available to women who need them. Given that abortion is a painful decision for women, there must be social support and compassion for women to make their own decisions. Where needed, safe methods of infertility treatment should also be made available to poor women, not merely fertility control.

Reproductive rights cannot be realized where the basic material needs of people are not met. Education, employment, and access to other economic resources are essential if people are to make their family-planning decisions freely. Thus, the very definitions of reproduction and family planning need to be enlarged to include the material needs of individuals, families, and communities. Continued avoidance of basic health and economic survival issues will only enable religious fundamentalist groups to present themselves as the guardians of family and community. This is beginning to happen in the area of HIV/AIDS prevention, which has been relatively neglected by family planners. The powerful evangelical Christian movement in the United States is beginning to take a leadership role in international HIV/AIDS prevention with the backing of the current U.S. government. While efforts to eradicate the deadly disease need to be welcomed, it is important to recognize that the fundamentalist Christians may use the opportunity to propagate their own moral values with regard to sexuality and gender norms and to advocate abstinence over protected sex.

In many regions, poverty eradication is also falling into the hands of internationally funded religious fundamentalist groups. Evangelical Christian groups in particular are stepping in to fill the social and economic vacuum created by privatization of state sectors and cutbacks in state social welfare accompanying economic globalization. But unlike the family planners who provide economic incentives to the poor for acceptance of sterilization or contraception, the religious proselytizers require religious conversion to their faith and the acceptance of their moral injunctions. These developments are adding further confusion and complexity to societies already torn asunder by other political-economic and cultural contradictions.

If poverty eradication is to be genuine, it must go beyond economic incentives given in exchange for contraceptive acceptance or religious conversion. In the long-term, poverty eradication calls for setting limits on corporate profit-making and on the widening gaps between the north and the south and between the rich and the poor within countries. In order to have democratic family planning, overconsumption of resources by rich families needs to be reduced and underconsumption by poor families needs to be augmented. The optimum balance between human well-being and environmental sustainability can be achieved through rational use of natural resources, sustainable economic production, and more equitable consumption.

The concepts of family and community need to be further extended, recognizing that childbirth and human reproduction are increasingly taking place outside male-headed nuclear families. It is necessary to find a more democratic approach toward reproductive rights and human liberation that transcends the extremes of both patriarchal right-wing fundamentalism and top-down authoritarian family planning. To do so, a balance needs to be struck between the traditional role of the self-sacrificing mother and the modern role of the individualist career woman. To find a middle path, women need support from men, their families, communities, work places, and the larger world. To confront the extraordinary challenges facing humanity, it is essential to create more loving and sustainable families. Family planning needs to move beyond the narrow focus of fertility control to treating humanity, if not all planetary life, as one extended family.

See also Equality: Gender Equality ; Eugenics ; Feminism ; Human Rights ; Third World .

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Asoka Bandarage

FAMILY PLANNING

The ability of couples to plan the size of their family and the timing of births has important sociological implications for both individual families and society as a whole. Women's roles and labor-force participation, the socialization of children, social and economic development, and ultimately the ability of the earth to sustain human life are all affected in one way or another by the ability of couples to practice family planning and the success with which they do so. In the United States, women expect to complete their childbearing with an average of 2.2 children per woman (Abma et al. 1997), and, on average, women have 2.0 births over their lifetime (Ventura et al.). Throughout the world, the average number of children desired varies from about two in most industrialized nations to between six and eight in some African nations (Alan Guttmacher Institute 1995). In order to limit lifetime births to the number desired, couples must abstain from intercourse, have high levels of contraceptive use, or resort to abortion. Indeed, sexually active women would average eighteen births over their lifetime if they used no contraception and no induced abortion (Harlap et al. 1991). This article summarizes information regarding sexual activity; the risk and occurrence of unplanned pregnancy; contraceptive use and failure; and the provision of family planning–related information, education, and services in the United States. For comparison, worldwide variation in the planning status of pregnancies and births and the use and availability of contraception are also presented.

EXPOSURE TO THE RISK OF PREGNANCY

Most Americans begin to have intercourse during their late adolescence and continue to be sexually active throughout their reproductive lives. In 1995, 55 percent of all men aged 15–19 in the United States had had intercourse (Sonenstein et al. 1998). Similarly, about half of all women aged 15–19 report ever having had sex (Table 1). These data, collected in 1995, indicate a leveling off in the trend toward earlier ages of sexual initiation. Whereas the percentage of adolescents who reported being sexually experienced rose steadily throughout most of the 1980s, the percentage of adolescent females who had ever had sex did not change significantly between 1988 and 1995 and the percentage of adolescent males who were sexually experienced actually fell during that period (Singh and Darroch 1999).

Once sexually active, most women become at risk for an unintended pregnancy. Table 1 shows information on the percentage of all U.S. women aged 15–44 who are at risk for becoming pregnant by age and union-status groups (currently married, cohabiting, formerly married or never married). The proportion who are not at risk of an unintended pregnancy because they have never had intercourse decreases quickly from 50 percent of teenagers 15–19 to only 1 percent of all women aged 35–44. Five to seven percent of women in all age groups have had intercourse but are not currently in a sexual relationship (i.e., they have not had sex within the last three months). Some 5 percent of women are infertile, or noncontraceptively sterile, because of illness, surgery (that was not for contraceptive purposes), menopause, or some other reason. The proportion that is infertile increases steadily with age, from 1 to 2 percent of women under 30 to about 13 percent of those aged 40–44. Some women, especially those in their twenties and early thirties, are not at risk of an unintended pregnancy because they are already pregnant, postpartum, or seeking pregnancy. Eleven to fifteen percent of women aged 20–34 are in this category.

Women who are at risk for an unintended pregnancy account for more than two-thirds of all women ages 15–44 at any point in time. Women at risk are those who are currently in a sexual relationship, are fertile, and wish to avoid becoming pregnant. The proportion of women at risk of unintended pregnancy increases from less than 40 percent of teenagers to about three-quarters of all women ages 25–44. Women who are currently married or cohabiting are most likely to be at risk for unintended pregnancy—81 to 83 percent of them are at risk, compared with 72 percent of formerly married women and 49 percent of nevermarried women. The most common reason some married or cohabiting women are not at risk of unintended pregnancy is that they are pregnant, postpartum, or trying to become pregnant. Among women who have never been married, never having had intercourse or no recent intercourse are the most common reasons.

OCCURRENCE OF UNINTENDED PREGNANCY

Nearly one-half of all pregnancies (49 percent) in the United States are unintended (Henshaw 1998), that is, they occur to women who want to have a baby later but not now (generally called "mistimed") or to women who did not want to have any (more) children at all (called "unwanted") (Table 2). The proportion of pregnancies that are unintended is highest among adolescents—78 percent—and varies considerably by age. The percentage of pregnancies that are unintended is lowest among women aged 30–34 (33 percent) and rises again among older women to 51 percent among women aged 40 and older. Unintended pregnancies are also relatively more likely to occur among never-married women (78 percent), black women (72 percent), and low-income women (61 percent for women under 100 percent of the federal poverty level).

The percentage of pregnancies that are unintended has declined in recent years—from 57 percent in 1987 to 49 percent in 1994 (see Table 2). These declines have occurred across all age categories but have been more significant among older women. These declines have also been more significant among low-income women. In 1987, 75 percent of all pregnancies to women with family incomes under 100 percent of the poverty level were unintended. This dropped to 61 percent in 1994. In comparison, the percentage of unintended pregnancies to women with incomes 200 percent or more of the federal poverty level fell from 45 percent in 1987 to 41 percent in 1994.

Among all unintended pregnancies, more than half (54 percent) end in an abortion while 46 percent result in an unintended birth. This relationship differs for adolescents, who, in recent years, have been more likely to resolve unintended pregnancies with a birth. More than one-half of all unintended pregnancies to adolescents result in an unintended birth (55 percent), while 45 percent are resolved with an abortion. These percentages represent a significant change in the resolution of unintended pregnancies among adolescents. Throughout the 1980s, adolescents who were pregnant unintentionally were more likely to obtain an abortion (55–53 percent) than to carry the pregnancy to term.

Nearly half (48 percent) of all women aged 15–44 have had at least one unintended pregnancy at some time in their lives; 28 percent have had one or more unplanned births, 30 percent have had one or more abortions, and 11 percent have had both. Given current rates of pregnancy and abortion, by the time they are 45 years old, the typical woman in the United States will have experienced 1.42 unintended pregnancies and 43 percent will have had an abortion.

Women who are using no contraceptive method account for about 8 percent of all women at risk of unintended pregnancy, but, because they are more likely to become pregnant than are those using a method, they account for nearly one-half of all unplanned pregnancies, an estimated 47 percent. Significant reductions in unintended pregnancy and abortion could occur with increased contraceptive use, with more effective use of existing methods, and with the development and marketing of additional methods.

CONTRACEPTIVE USE

Women and men in the United States rely on a variety of contraceptive methods to plan the timing and number of children they bear and to avoid unintended pregnancies. Surgical contraceptive sterilization is available to both men and women. Oral contraceptives, Depo Provera injectibles, Norplant implants, the IUD, and female barrier methods such as the diaphragm and the cervical cap are available from physicians and clinic providers. Other methods—condoms and spermicidal foam, cream, jelly, and film—can be purchased over the counter in pharmacies or other stores. Instruction in periodic abstinence is available from physicians and other family planning providers as well as through classes where only that method is taught.

More than nine in ten women aged 15–44 in 1995 who were at risk of unintended pregnancy

were using a contraceptive method, as shown in Table 3. Thirty-six percent relied on contraceptive sterilization of themselves or their partner, 52 percent used reversible medical methods, 5 percent used nonmedical methods such as withdrawal and periodic abstinence, and 7.5 percent were currently using no contraceptive, even though they were at risk of unintended pregnancy.

Patterns of contraceptive use differ by age. Younger women at risk of unintended pregnancy are more likely than older women to use no method of contraception. Nearly one in five teenage women at risk use no method, compared to 6 to 7 percent of women at risk aged 25 and older. The proportion using reversible medical methods declines steeply with age—from more than four out of five women aged 20–24 to less than one-quarter of those ages 40–44. Oral contraceptives are the most commonly used method among women under 30, used by 35 to 48 percent of these women. Condoms are second in popularity among this age group, used by 23 to 30 percent of women. Although fewer than 3 percent of women at risk use Depo Provera injectible contraceptives, this method has grown in popularity since its introduction into the United States, particularly among young women. Eight percent of teenagers at risk used this method. As women become older and complete their families, male and female contraceptive sterilization become increasingly common, rising steeply from 5 percent of women at risk aged 20–24 to one in five women in their late twenties and to two out of three women aged 40–44. Among women in their twenties, female sterilization is about four times more common than vasectomy. The margin narrows among older women to between two and two and a half times more common.

The proportion of women at risk of unintended pregnancy who use no contraceptive method is highest among never-married women, 14 percent as compared to 5 percent of those who are currently married or cohabiting and 8 percent of formerly married women. Sterilization is the most frequently used method among women who are currently married (46 percent) as well as formerly married women (50 percent). The pill is the most commonly used method among never-married women (38 percent) and cohabiting women (34 percent). Condoms are most likely to be used by never-married women (28 percent).

Although poor women and minority women at risk of unintended pregnancy have, in the past, been more likely than higher-income and nonHispanic white women to be using no contraceptive method, these differences have lessened. Compared to the 1980s, in 1995 there were no significant race/ethnicity or poverty differences in the percentages of women at risk of unintended pregnancy who used no method of contraception. However, there is some variation in the types of methods used among these subgroups. Low-income women are less likely to rely on reversible methods and more likely to rely on sterilization than higher income women. Forty percent of women at risk of unintended pregnancy who are under

150 percent of the poverty level use sterilization compared to 32 percent of women at 300 percent of the poverty level and above. Poor women relying on sterilization are much more likely than higher-income women to have been sterilized themselves rather than have a partner who has had a vasectomy. Female sterilization accounts for 92 percent of all contraceptive sterilization among poor women, compared with 58 percent among those with higher incomes.

CONTRACEPTIVE EFFECTIVENESS

Pregnancies occur to couples using contraceptive methods for two reasons—because of the inadequacy of the method itself or because it was not used correctly or consistently. Estimates have been made (either theoretically or empirically during clinical trials) regarding the efficacy of each contraceptive method given perfect use (Trussell 1998). In addition, estimates are made that measure the typical use effectiveness of each method, which relates to the experience of an actual group of users. The most recent estimates of typical use contraceptive effectiveness by method have been made using the 1995 National Survey of Family Growth, corrected for abortion underreporting and standardized for variation in the proportions of women from different subgroups using certain methods (Fu et al. 1999). Failure rates differ by method, with some methods consistently showing higher effectiveness than other methods. Rates also differ by sociodemographic subgroup within study populations.

Table 4 provides estimates of method-specific failure rates given both perfect use and typical use for the most commonly used reversible contraceptive methods. For each contraceptive method, the typical failure rates observed among women are substantially higher than the estimated rates given perfect use, and the rates differ widely among marital status, age, and poverty of women subgroups. The lowest failure rates are achieved with long-acting hormonal contraceptives that require little user compliance. Among methods that women must use daily or per coital episode, oral contraceptives are most effective, while spermicides, withdrawal, and periodic abstinence have the highest failure rates. In general, women who are young,

unmarried or cohabiting, and poor have higher failure rates. The differences in failure rates between methods and between subgroups of women are much greater than what any difference in method effectiveness or in the biology of women would cause and are assumed primarily to reflect differences in the correctness and consistency of method use (although reporting errors may also play a role).

FAMILY PLANNING INFORMATION AND EDUCATION

Rising public concern over the occurrence of unintended pregnancy and, particularly, of unintended, nonmarital adolescent pregnancy and childbearing in the United States has drawn attention to the manner in which young people are educated about sexuality, contraception, and how to avoid pregnancy and other negative consequences of sexual activity. Parents and other adults have long played a key role in controlling the sexual behavior of adolescents and in providing basic information about sex and pregnancy avoidance. During the past twenty-five years, there has been a proliferation of organized efforts to augment the information, education, and support traditionally provided by families. Beginning with programs and services for young pregnant women, these efforts have expanded to include legislative mandates regarding the teaching of sexuality or family life education in schools, development and distribution of a variety of sexuality-education curricula, as well as integrated community interventions and media involvement. Organized efforts to implement sexuality education and related activities have also been influenced by growing public concern and awareness of HIV/AIDs and the need to provide young people with the information and means to avoid infection.

Increasingly, policies and programs to encourage abstinence among unmarried teenagers have become popular. Some of these programs attempt to accomplish this objective by giving young people encouragement, offering moral support and teaching interpersonal skills to resist pressures to become sexually active. Others, which seek to convince teenagers that sex before marriage is immoral, emphasize the negative consequences of sexual intercourse, occasionally withhold or distort information about the availability and effectiveness of contraception (Alan Guttmacher Institute 1994a). In fact, although most public schools provide some sort of sexuality education to middle or junior and senior high school students, the education provided is often too little, too late.

On a broader scale, community and service organizations have implemented interventions aimed at increasing the life options of disadvantaged young people through, for example, role models and mentoring, community service projects, job training, and activities aimed at reducing risky behaviors. Such interventions are expected indirectly to reduce levels of unintended teenage pregnancy, childbearing, and sexually transmitted infections, based on the belief that teenagers who are more positive about their futures are less likely to participate in risk-taking behaviors, including risky sexual practices.

Other policies or programs implemented with the hope of reducing unprotected teenage sexual behavior include (1) comprehensive school-based sexuality-education curricula that include discussion of abstinence but also include information about contraceptive methods and services; (2) programs that address the social pressures faced by teenagers to have sex and that provide modeling and practice of communication, negotiation, and refusal skills; (3) condom availability programs in schools; and (4) multicomponent programs that include communitywide activities—such as media involvement, social marketing, and links between school-based activities and contraceptive service providers (Alan Guttmacher Institute 1994a).

Evaluations of a variety of programs and approaches aimed at affecting teenage sexual and reproductive behavior, although still somewhat inconclusive, have shown that some programs have had a positive effect on the behavior of youth. In addition, results of multiple studies indicate that the provision of contraceptive information and access does not encourage young people to become sexually active at younger ages. Reviews of the evaluation research point to the need for integrated approaches that both address the antecedents of sexual risk taking (e.g., poverty, violence, social disorganization) and provide young people (who will soon become adults) with the information, skills, and resources to make responsible decisions about sexual behavior and the avoidance of unintended outcomes (e.g., Kirby 1997).

CONTRACEPTIVE SERVICE PROVISION

In the United States, women can receive contraceptive services from private practice general and family practitioners and obstetrician-gynecologists, as well as from publicly supported clinics run by hospitals, health departments, community health centers, and Planned Parenthood affiliates or independent clinic providers. In addition, some teenage and young adult women receive contraceptive services from school-based clinics and college or university health centers.

Private practice physicians are the most numerous providers in the United States that are available to women seeking contraceptive information and services. More than 40,000 family practice doctors and nearly 30,000 obstetriciangynecologists provide office-based outpatient services (Alan Guttmacher Institute 1997). About seven in ten women seeking family planning services report going to a private practitioner or health maintenance organization (HMO) for their care (Aloma et al. 1997).

Annually, some 6.5 million U.S. women receive contraceptive services, supplies, and information from more than 7,000 publicly supported family planning clinics, located in 85 percent of all U.S. counties (Frost 1996). Family planning clinics, using a combination of federal, state, and local funds, provide care to those who cannot afford services from private physicians or who cannot use private physicians for other reasons. In most clinics, fees are based on the client's ability to pay, confidential services to teenagers are assured, and a full range of contraceptive methods are offered. As a result, family planning clinic clients are primarily low-income (57 percent are below 100 percent of the federal poverty level, and 33 percent are between 100 percent and 249 percent of the federal poverty level) and young (20 percent are under age 20; 50 percent are aged 20–29). Although a majority of clinic clients are non-Hispanic whites, nearly 40 percent are minority women (19 percent are black, 14 percent are Hispanic, and 7 percent are Asian or other races) (Frost and Bolzan). Lower-income women go to clinics primarily because they cannot afford physicians' fees, because the clinic is more conveniently located, or because the clinic will accept Medicaid payment. Adolescents often go to clinics because of the free or low-cost services and because they are afraid a private physician will tell their parents about their contraceptive use. In addition, some women, especially teenagers who have never been to a physician on their own, go to clinics because they do not know a physician who would serve them. Clinic clients usually shift to private physicians when their incomes rise and as they become older.

Sixty percent of all publicly supported clinics receive federal Title X support and must therefore follow federal standard of care guidelines. These guidelines provide medical protocols as well as mandates regarding confidentiality and key areas of outreach that clinics should seek to address. As a result, many publicly supported clinics provide outreach and information or education in local schools or in other community locations. These clinics often seek to reach out to women (and men) in need of contraceptive care who have special needs or risk factors for unintended pregnancy (e.g., because of homelessness, drug or alcohol abuse, domestic violence, or other reasons).

The provision of contraceptive services, like all areas of health care, has been affected by changes in the structure of health care financing and the rise of managed care. In the past, most privately insured women had employer-based indemnity health insurance plans that rarely covered either routine gynecological checkups or reversible contraceptive services and supplies. However, such plans often covered sterilization services. Today, most privately insured women are enrolled in managed care plans. These plans are more likely to cover preventative care, including routine gynecological checkups and some reversible contraceptive services and supplies. However, not all managed care plans cover all or even most methods, and often the process of obtaining contraceptive services within managed care plans places additional burdens on women seeking contraceptive care. These burdens include prior authorization requirements that may cause some women to delay care or forgo sensitive care that a woman may not want to disclose to her primary care physician (Alan Guttmacher Institute 1994b, 1996).

INTERNATIONAL COMPARISONS

Women in the United States have both similarities and differences with women throughout the world in their efforts to plan the number and timing of children. In adolescence, American women are somewhat less successful in their attempts to prevent unplanned pregnancies than are young women in most other industrialized countries. Table 5 presents recent birthrates among women aged 15–19 for selected European and North American countries. Although there is no evidence that young women in the United States are more (or less) sexually active than young women in many other industrialized countries, the United States has adolescent birthrates that are nine to ten times higher than the rates for the Netherlands and Sweden and more than twice as high as the rates for Canada, England, and Wales. The factors responsible for these differences are not entirely clear; however, it is likely that they are due in part to differences in the levels of disadvantage among countries, to variation in the family planning education and services provided to youth and to greater or lesser openness regarding sexuality among countries.

In developing countries, young women marry earlier and have children at younger ages than in the United States. More than half of the young women in sub-Saharan Africa bear a child during the teenage years and about one-third of the young women in Asia, North Africa, the Middle East, and Latin America bear children as teens, compared to just one-fifth of teenage women in the United States. Although the situation is improving and the proportion of adolescents using contraception is increasing in many developing countries, few married adolescents use contraceptive methods and high percentages of sexually active unmarried adolescents rely on traditional nonmedical methods, such as withdrawal and periodic abstinence. Greater use of reliable contraceptive methods by adolescents worldwide is often hampered by inadequate or inaccurate information, poor access to services, and community expectations that value early childbearing within marriage and punish sexual activity outside of marriage. As a result, a substantial proportion of births to adolescents are unplanned—40 to 60 percent in several Latin American and sub-Saharan African countries, and 20 percent or more even in countries where almost all births are to married adolescents. By comparison, 66 percent of adolescent births in the United States are unplanned (Alan Guttmacher Institute 1998).

The patterns of pregnancy, childbearing, and contraceptive use among women of all ages vary from region to region throughout the world. Table 6 presents information on pregnancy rates

(per 1,000 women aged 15–44), planning status of pregnancy, abortion, and contraceptive use for women in different regions of the world. Women in Africa experience the highest rates of pregnancy, the lowest percentage of pregnancies aborted, and the highest percentage of married women using no contraceptive method. Although women in the United States have somewhat higher pregnancy rates than women in most of Europe and other North American countries, they have significantly lower pregnancy rates than most of the women in the rest of the world. The percentage of pregnancies that are planned varies considerably among the different regions of the world, from only 25 percent of pregnancies in eastern Europe being planned to 54 percent of African pregnancies being planned. Similarly, there is variation in the percentage of pregnancies that are aborted and in the patterns of contraceptive use. Compared to other regions of the world, the percentage of U.S. pregnancies that are aborted is similar to that in most of Europe and Latin America but less than half the percentage in eastern Europe. In terms of contraceptive use, married women in the United States are more likely than women in most other regions of the world (except for East Asia) to choose sterilization as their method of contraception. Married women in Africa and in Europe (both eastern and western Europe) rarely choose sterilization, and high percentages of Europeans rely on nonmedical methods, such as withdrawal.

Worldwide, only 47 percent of all pregnancies (including miscarriages) are planned and, at the same time, 42 percent of married women are using no method of contraception. In most regions of the world, one-third or more of married women use no method. Ensuring greater information, education, and access to family planning services worldwide has the potential to greatly reduce the level of unplanned pregnancy and abortion.

(see also: Birth and Death Rates; Family Size; Fertility Determinants; Pregnancy and Pregnancy Termination)

references

Abma, J. C., et al. 1997 "Fertility, Family Planning, and Women's Health: New Data from the 1995 Survey of Family Growth." Vital and Health Statistics, Series 23, No. 19, Table 1.

Alan Guttmacher Institute 1994 Sex and America's Teenagers. New York: Alan Guttmacher Institute.

——1994b Uneven and Unequal: Insurance Coverage and Reproductive Health Services. New York: Alan Guttmacher Institute.

——1995 Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences. New York: Alan Guttmacher Institute.

——1996 Improving the Fit: Reproductive Health Services in Managed Care Settings. New York: Alan Guttmacher Institute.

——1997 Contraceptive Needs and Services. New York: Alan Guttmacher Institute.

——1998 Into a New World: Young Women's Sexual and Reproductive Lives. New York: Alan Guttmacher Institute.

——1999 Sharing Responsibility: Women, Society and Abortion Worldwide. New York: Alan Guttmacher Institute.

Forrest, J. D. "Epidemiology of Unintended Pregnancy and Contraceptive Use." American Journal of Obstretics and Gynecology 170(5):1485–1489.

Frost, J. 1996 "Family Planning Clinic Services in the United States, 1994." Family Planning Perspectives 28(3)92–100.

——, and M. Bolzan 1997 "The Provision of Public Sector Services by Family Planning Agencies in 1995." Family Planning Perspectives 29(1)6–14.

Fu, H., J. E. Darroch, T. Haas, and N. Ranjit 1999 "Contraceptive Failure Rates: New Estimates from the 1995 National Survey of Family Growth." Family Planning Perspectives 13(2):56–63.

Harlap, S., K. Kost, and J. D. Forrest 1991 Preventing Pregnancy, Protecting Health: A New Look at Birth Control Choices in the United States. New York: Alan Guttmacher Institute.

Henshaw, S. K. 1998 "Unintended Pregnancy in the United States." Family Planning Perspectives 30(1)24–29, 46.

Kirby, D. 1997 "No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy." (Research review commissioned by The National Campaign to Prevent Teen Pregnancy Task Force on Effective Programs and Research, Washington, D.C.)

Singh, S., and J. E. Darroch 1999 "Trends in Sexual Activity Among Adolescent American Women: 1982–1995." Family Planning Perspectives 31(5):212–219.

——, and J. E. Darroch, Forthcoming "Adolescent Pregnancy and Childbearing: Levels of Trends in Developed Countries." Family Planning Perspectives.

Sonenstein, F. L., et al. 1998 "Changes in Sexual Behavior and Condom Use Among Teenaged Men: 1988 to 1995." American Journal of Public Health 88(6):956–959.

Trussell, J. 1998 "Contraceptive Efficacy." In R. A. Hatcher et al., eds., Contraceptive Technology, 17th rev. ed. New York: Ardent Media.

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Ventura, S. J., et al. 1998 "Births and Deaths: Preliminary Data for 1997." National Vital Statistics Reports 47(4):4.

Jennifer J. Frost

Jacqueline E. Darroch

Family Planning

BIBLIOGRAPHY

Family planning is a term created in the mid-twentieth century to refer to the ability to control reproduction through access to contraception, abortion, and sterilization, in addition to access to information and education. Reproductive control allows a woman to determine when and whether she will have children. A woman’s ability to control the birth and spacing of her children has a direct impact on her educational, economic, and social opportunities. A woman’s enjoyment of heterosexual activity can be affected by the fear of becoming pregnant if she lacks information about, or access to, contraception and abortion.

Women have found ways to control their reproduction since the earliest days of recorded history. However, these methods have not always been safe or effective. By 1900, every method of contraception (chemical, barrier, and natural means) had been invented, except for the anovulant method (the contraceptive pill and related methods of hormone regulation developed in the mid-twentieth century). Access to contraception was limited by law or by technological inferiority. In the United States, contraception and abortion were available through midwives, with a variety of contraceptive methods also available in the open market and through the advice of friends and family. With industrialization, urbanization, and the advent of new reproductive technologies, there was a shift away from women’s ability to control their reproductive lives. By 1900, every state had criminalized abortion in most circumstances. In 1873 Congress passed the Act of the Suppression of Trade in and Circulation of, Obscene Literature and Articles of Immoral Use. The Comstock Law, as it was known, was named for the U.S. Postal agent, Anthony Comstock (1844–1915), who lobbied for the bill’s passage. The law criminalized, among other things, the distribution of information and materials related to contraception and abortion through the U.S. mail. Legal or not, women often found means of controlling their reproduction, utilizing methods which were sometimes ineffective, dangerous, or in some cases deadly.

In the first decades of the twentieth century, social activists such as Margaret Sanger (1879–1966) and some members of the medical profession initiated a campaign for legalized contraception. Sanger was born into a large working-class family. She attended nursing school and later served as an obstetrical nurse in the Lower East Side of New York City. From her experiences as a nurse and as a child among eleven in her family of origin (her mother died at a young age as a result of multiple pregnancies within a short span of years), Sanger recognized the connection between the inability to regulate fertility and families’ economic struggles as well as women’s health. Later in life, Sanger would recall stories of women who begged her for information on how to avoid having more children or who fell ill and in some cases died as a result of a botched, illegal abortion.

Sanger’s efforts to find information on safe, legal, and effective means to regulate women’s fertility merged easily with her socialist perspective. In her socialist-feminist periodical, The Woman Rebel, Sanger first coined the term birth control in 1914. In the same year, she authored and published a pamphlet on methods of contraception, Family Limitation, based on her research on techniques and technologies of contraception available around the world. With her international research in hand, Sanger opened the first birth control clinic in the United States in 1916. One year later, she began to publish the periodical Birth Control Review. For more than a decade, the Birth Control Review provided readers with news and information on the fight for the legalization of contraception in the United States and overseas. In addition, Sanger traveled widely, organizing speaking tours and international conferences in an effort to coordinate the efforts of medical and social advocates for birth control. Thanks to the work of Sanger and others like her, by the mid-1930s various court rulings allowed contraception to be more widely available in the United States. Sanger’s American Birth Control League (founded in 1921) merged with other advocacy groups to become the Planned Parenthood Federation of America in 1942.

Sanger’s socialist roots in the birth control movement later evolved into a mainstream call for “planned parenthood”—the appropriate spacing of pregnancies to protect the health of mothers and children. The advent of the contraceptive pill in the United States in the 1960s led to a philosophical shift from birth control as a means of spacing pregnancies to a connection with the women’s liberation movement—freeing women from a fear of pregnancy, allowing them to focus on their careers and shape their own destiny.

Sanger remains a controversial figure in American history. Because she founded Planned Parenthood, critics of abortion connect her work with the abortion services offered at Planned Parenthood clinics across the country. In vilifying its founder, they attempt to discredit her organization. However, Sanger repeatedly separated the provision of abortion from contraception. She believed that contraception was the best way to prevent abortion. A second controversy attached to Sanger is the assertion that she was racist. This is the result of her reliance on eugenics discourse in her speeches and articles in the 1920s and 1930s. Her support for the provision of contraception in the African American community and overseas (in China, for example) has fueled this argument. Eugenics, the science of selective breeding, has a long history. Before World War II (1939–1945), it was a term invoked by many in mainstream society, including politicians, physicians, and professors. Eugenicists often called for the use (sometimes compulsory) of birth control (sterilization or contraception) to create a more stable, wealthier society by eliminating society’s weakest elements. While some in the eugenics movement focused on health concerns (mental and physical problems), others concentrated on moral concerns (alcoholism and criminal behavior). At its most extreme, racial prejudice led Caucasian middle- and upper-class eugenicists to blame the burgeoning African American and immigrant communities for the nation’s problems. An examination of Sanger’s perspective on eugenics reveals that her focus was on health and economic improvement (smaller families have a higher standard of living) and was not specifically connected with race.

Contraception was still illegal in many states in the mid-twentieth century until the U.S. Supreme Court, in Griswold v. Connecticut, overturned a Connecticut law banning contraceptive use in 1965. The Court ruling legalized contraceptive access for all married persons, based on the right to privacy. In 1972, in Eisenstadt v. Baird, the Court expanded the right to access to contraceptives to include unmarried people—again, based on the right to privacy. The same right was invoked in the Roe v. Wade decision in 1973, when the U.S. Supreme Court legalized abortion in the first two trimesters of a pregnancy.

Within years of the Roe v. Wade ruling, reproductive rights were again limited by law. Between 1996 and 2004, 335 new state laws were created to restrict access to abortion services. Access to abortion was limited by income (the prohibition on Medicaid funding for abortions) and age (parental consent laws instituted at the state level). Other obstacles to access were also created in many states, such as waiting periods mandated between the time of the consultation and the procedure. By 2004 just 13 percent of U.S. counties had an abortion provider. This was the result of both restrictive state legislative action and violence (and the threat of violence) against clinics and clinic personnel.

In 1999 the U.S. Food and Drug Administration approved emergency contraceptives (the “morning-after pill”) for distribution with a prescription. Emergency contraception is a stronger dose of the standard contraceptive (anovulant) pill and is effective within seventy-two hours of unprotected intercourse. It prevents the implantation of a zygote (if there is one) on the uterine wall. As its name suggests, it is intended to prevent pregnancy if contraception fails or in the case of sexual assault. In 2006, following years of politically charged debate, the FDA approved emergency contraception for over-the-counter sales (without a prescription) for women over age eighteen.

A chemical abortifacient, RU-486 (named for the French pharmaceutical company Roussel-Uclaf, which patented it), was approved by the FDA in 2000. Women in Europe had used the drug since 1988. In U.S. tests, RU-486 was shown to be 92 percent effective in terminating pregnancies before the seventh week of gestation. The abortion pill was heralded as an alternative to surgical abortion, providing a more private experience—away from the clinics that are the focal point for abortion protesters.

Immediately following the Roe v. Wade decision, the religious and conservative right organized opposition to abortion. However, legislative lobbying and clinic protests against abortion have widened in scope to attacks on certain contraceptive methods. Those who believe life begins at conception see some methods—the contraceptive pill, the “morning-after pill,” and intrauterine devices—as abortifacients because they act to prevent pregnancy after a zygote has been created. Physicians and pharmacists opposed to abortion may refuse to prescribe, or fill prescriptions for, these forms of contraception. Pro-choice forces, on the other hand, hope to prevent abortion through increased access to contraception and comprehensive sex education. Because abortion is a debate of absolutes, pro-life and pro-choice forces will continue to be engaged in this issue.

SEE ALSO Abortion; Birth Control; Contraception; Eugenics; Family Structure; Fertility, Human; Population Control; Population Growth; Pro-Choice/Pro-Life; Roe v. Wade; Supreme Court, U.S.

BIBLIOGRAPHY

Chesler, Ellen. 1992. Woman of Valor: Margaret Sanger and the Birth Control Movement in America. New York: Simon & Schuster.

Feldt, Gloria, with Laura Fraser. 2004. The War on Choice: The Right Wing Attack on Women’s Rights and How to Fight Back. New York: Bantam Books.

Gordon, Linda. 2002. The Moral Property of Women: A History of Birth Control Politics in America, 3rd ed. Urbana and Chicago: University of Illinois Press.

McCann, Carole R. 1994. Birth Control Politics in the United States, 1916–1945. Ithaca, NY: Cornell University Press.

Reagan, Leslie J. 1997. When Abortion Was a Crime: Women, Medicine, and Law in the United States, 1867–1973. Berkeley: University of California Press.

Sanger, Margaret. 1938. Margaret Sanger: An Autobiography. New York: Norton.

Julie L. Thomas

Family Planning

Family planning is both a descriptive term and an organizational one. It was originally conceived as a public relations effort to emphasize the broadened scope of those involved in the struggle to spread the concept of birth control. The term achieved popularity in England before it did in the United States, and in May 1939, various British birth control groups amalgamated into the Family Planning Association, including in their program treatment for infertility and minor gynecological problems, child spacing, and contraceptive instruction and equipment. In the United States the name of the American Birth Control League was changed to the Planned Parenthood Federation in 1941 to emphasize the broad focus of family planning. The Planned Parenthood name was also adopted by the international federation that formed after the end of World War II, and family planning or planned parenthood became universal descriptors.

Broadly defined, family planning is the act of making a conscious plan about the number and timing of children's births. Timing may include the time of the first birth, the amount of space between births, and when to stop having children. It can include abortion, a discussion of the various means of contraception, and fertility testing and even treatment. Family planning involves not only the individual or couple, but society as well.

Methods and Effectiveness

People have consciously or unconsciously engaged in family planning throughout history. Abstinence, either lifelong or temporary, and prohibitions forbidding intercourse during certain times of the year or during certain festivals effectively curtail the fertility rate (the number of live births for each women during her lifetime). Separation of husbands and wives for long periods of time by war or business trips also curtails the fertility rate.

Abortion has often been used to limit family size, and descriptions of abortifacients, or agents that cause abortion, can be found in the herbal and other folklore of women and midwives of most societies. The deliberate abandonment of infants and young children, even killing of newborns, has not been uncommon in the past or even in some areas of the world today. Although the early Christian Church outlawed infanticide, it emphasized the stigma of illegitimacy, which meant that out-of-wedlock infants were brought to overcrowded orphanages and monasteries, where the majority of them died of starvation or disease within a few months.

Prolonged lactation is also a factor in spacing births. Lactation and the stimulus of the infant sucking ordinarily suppresses ovulation and menstruation, but it is highly effective as a birth control mechanism only when the infant consumes nothing but breast milk or when couples normally abstain from intercourse during lactation. As partial weaning takes place—as early as four to six months—the menstrual cycle returns in most women who are adequately nourished, and pregnancy is again possible.

Numerous devices such as condoms and IUDS (intrauterine devices) have been and still are used in family planning. Alternate methods of intercourse, including withdrawal and anal intercourse, also lessen the chance of pregnancy. One of the earliest results of the use of broad-scale methods sufficient to affect national fertility was the decline in the French birth rate from the end of the eighteenth century, a decline attributed to the widespread use of coitus interruptus (Van de Walle 1978). The continuing search for means of controlling contraception emphasizes an almost universal desire for humans to gain some control over the number and spacing of births.

The effectiveness of family planning is measured by the fertility rate, the total number of live births a woman at age fifty would have had. The replacement rate for a stable population is over two and under three. In the twentieth century, many countries had fertility rates below the replacement ratio but still gained population because people were living longer and several generations of a family were alive at the same time. In determining potential rates of increase without any family planning, demographers traditionally have used Hutterite women as their maximum standard for potential. The Hutterites are members of a religious denomination (in the northern United States and Southern Canada) who in the past did not use any method of family planning, although evidence suggests that this is changing. Their living standard is not luxurious, but their food supply is more than adequate, and they are regarded as very healthy. Hutterite women bore an average of twelve children in the early part of the twentieth century (Coale 1971), and this has been considered the maximum for a totally uninhibited rate of fertility that only could reached under the best possible conditions. Current fertility rates in some countries of the Third World, such as Saudi Arabia, Malawi, and Rwanda, were between seven and eight at the beginning of the 1990s, but even these had dropped to between six and seven at the end of the decade (International Planned Parenthood Federation 2002), indicating the growing influence of family planning.

Social Regulation

Organized efforts at family planning began to appear in the nineteenth century although, as in the case of France, some forces were at work earlier. The nineteenth-century efforts were started by individuals concerned with the poverty and malnutrition that seemed to be endemic among large families. Governmental bodies initially paid little attention to such efforts, and when they did they often opposed the advocates of family planning. In the United States, for example, governmental agencies such as the post office in the last part of the nineteenth century classified family planning materials as pornography. At the beginning of the twentieth century, President Theodore Roosevelt compared women who avoided pregnancy to men who refused to serve in the armed services in time of great national emergency. He argued that U.S. women had a patriotic duty to have children. Not until the last part of the twentieth century did governments in general take direct or indirect action to encourage family planning. This concern came primarily because of a growing concern about overpopulation, but it also reflected the growing influence of women on national policy.

At the beginning of the Industrial Revolution in the eighteenth century, the world population was estimated at 750 million. With growing urbanization and industrialization, growth escalated rapidly, reaching one billion in 1830, two billion in 1930, three billion in 1960, five billion by 1990, and six billion in 2000. It will probably continue to grow— unless there is radical change in trends—until 2020, after which a slow decline will begin. The growth, as indicated above, is due to declining mortality as the standard of living and sanitation have improved and communicable diseases controlled. The most rapid growth has not been in the highly industrialized countries but in those that have not yet industrialized. As the standard of living has risen in Western Europe, the United States, and similar countries, the fertility rate by 1990 had already fallen below two and in some as low as one and three-tenths (Green 1992).

Most countries have relied on education in family planning to lower fertility rates, although more drastic means have also been used. In India, for example, the government of the late Indira Gandhi was forced to cut back on their program because it was alleged that sterilization was being forced on the less educated peasants. The problem of overpopulation is compounded in many of the underdeveloped countries because the largest segment of their population is in the childbearing years. In these places, even with the more or less drastic lowering of fertility ratios, population will continue to grow. The People's Republic of China in the 1980s became the first country in the world to embark on a deliberate and comprehensive course to reach zero population growth by the end of 2000 or as soon after that as possible. In spite of drastic efforts to limit families to one child, forcing families in the cities to get permission to even try to get pregnant, and the use of drastic sterilization and abortion programs, the country failed to meet its goal, and its population in 2001 was nearly 1,300,000,000. It is, however, well on its way to doing so, and soon it will be surpassed as the country with the largest population by India (which stands at 1,034,000,000).

The Chinese policy uses, on the one hand, the carrot and stick, with promises of better schooling and other rewards for families who have only one child, and on the other hand, forced abortions or sterilizations for those who have more. In 1993 the government approved a bill to forbid marriages of persons with hepatitis and other sexually transmitted diseases, mental illness, and congenital disabilities, but the Chinese experiment emphasizes the difficulty that even authoritarian states have in encouraging family planning. In the United States, where the fertility rate is under two, in the year 2000 more than 30 percent of the women did not use any modern mechanical or chemical method of contraception. Half of the U.S. pregnancies are believed to be unplanned or unwanted, a rate that is higher than in most other industrial countries. This is one reason for the high—although declining— abortion rate in the United States. Most of the pregnancies in the United States occurred among women who came from disadvantaged backgrounds and were under twenty-five. This suggests that in general, not everyone in the United States has fully changed to the belief in an overpopulated world. How much they should change their beliefs is a matter of public discussion. That fact that not all the U.S. states gave people access to contraception until 1965, and that abortions were prohibited until 1973, emphasizes the difficulty family planning had in being accepted.

Evidence suggests that about 600 million people use contraception, and millions more would do so if they had access to high-quality services. To reach them, family planning advocates have adopted an educational four-point program that points out what family planning does: First, it saves women's lives. Avoiding unintended pregnancies could prevent about one-fourth of all maternal deaths in developing countries. Using contraceptives helps women avoid unsafe abortions, limit birth to their healthiest childbearing years, and prevent giving birth more times than is good for their health. Second, family planning saves children's lives. Spacing pregnancies at least two years apart helps women have healthier children and improves the odds of infants' survival by about 50 percent. Limiting births to a woman's healthiest childbearing years also improves her children's chances of surviving and remaining healthy. Third, women are given more choices. Controlling their own childbearing by using effective contraception can open the door to education, employment, and community involvement. Couples who have fewer children are more likely to send their daughters as well as sons to schools. Fourth, family planning encourages the adoption of safer sexual behavior. All sexually active people need to protect themselves against sexually transmitted infections (STIs), including HIV/AIDS. Using condoms or avoiding sex except in a mutually monogamous relationship are the best ways to do so. Advocates also emphasize that effective family planning helps protect the environment and aids economic development by slowing population growth.

Although governments increasingly have taken an active role in pushing family planning, many professionals believe that the keys to success are also encouraging individual advocacy—presenting stories of people's personal experiences showing how family planning improves individual lives— and encouraging nongovernmental organized groups to carry out educational campaigns. Several published guides on advocacy are available, including International Planned Parenthood Federation's Advocacy Guide and the Population Information Program at Johns Hopkins University, A Frame for Advocacy. The optimal situation for family planning involves a discussion between both members of the couple before they begin to have sexual relations and includes a sharing of mutual hopes and desires to make sure they are sufficiently congruent to achieve a good marriage or partnership. These discussions should include all aspects of planning (whether marriage will occur and when, whether children are planned and when, and the number and spacing of children). They should consider early in the discussion whether the individual man or woman wants to have children. Most young people want at least one child, although they may change their minds over time. If a couple decides to have children, they must then plan the number of children. People make these decisions in the context of the norms of their individual groups, although it is good to keep in mind that such norms can also change, which emphasizes the need for ongoing discussion.

Infertility

Perhaps the best indicator of the North American and increasingly worldwide desire for children is the growing ongoing concern with infertility, something that is also part of family planning. Somewhere between 10 and 15 percent of all couples have difficulty conceiving, with the causes about equally divided between men and women. Major causes include venereal infections, failure to ovulate, low sperm count, obstructions in either the male or female reproductive organs, and impenetrable cervical mucus. Sometimes these problems can be treated with antibiotics, surgery, or hormones. If these methods fail, couples may also try artificial insemination or in vitro fertilization— approaches that have have been successful for many couples. The down side to their use, however, is that now that these technological approaches to conception are available, some couples feel obligated to try to have a baby. The complex approaches, including in vitro fertilizations, are expensive, time consuming, and often disappointing.

Conclusion

Ideal family planning includes consideration of the timing of marriage, number and spacing of children, and when the first and last births will occur. It requires that couples discuss sexuality, contraception, and other long-range plans such as schooling or work plans that affect births. North Americans still do little of this planning, and teenagers receive insufficient instruction about these topics. Family planning should be an important part of the modern lifestyle. If individuals do not take on this responsibility, there is always the potential that government, as in the case of China, will see a need to intervene.

See also:Abortion; Acquired Immunodeficiency Syndrome (AIDS); Abstinence; Assisted Reproductive Technologies;Birth Control: Contraceptive Methods; Birth Control: Sociocultural and Historical Aspects; Childcare; Childlessness; Circumcision; Fertility; Hutterite Families; Infanticide; Pregnancy and Birth; Sexuality; Sexuality Education; Sexually Transmitted Diseases; Single-Parent Families

Bibliography

bullough, b., and bullough, v. (1998). contraception.buffalo, ny: prometheus books.

bullough, v. (2001). encyclopedia of birth control. santabarbara, ca: abc-clio.

bullough, v., and bullough, b. (1983–84). "populationcontrol vs. freedom in china." free inquiry 3:12–15.

bullough, v., and bullough, b. (1995) sexual attitudes: myths and realities. buffalo, ny: prometheus.

central intelligence agency. (1998). the world factbook1997–98. washington, dc: brassey.

cleland, j., and hobcraft, j., eds. (1985) reproductivechange in developing countries: insights from the world fertility survey. oxford, uk: oxford university press.

coale, a. j. (1971). "the decline of fertility in europe from the french revolution to world war ii." in fertility and family planning: a world view, ed. s. j. behrman, l. cors, jr., and r. freedman. ann arbor: university of michigan press.

freeman, s., and bullough, v. (1993). the complete guide to fertility planning. buffalo, ny: prometheus.

green, c. p. (1992). the environment and populationgrowth: decade for action. supplement to population reports, series m., no. 10, vol. 20. baltimore: population information program, the johns hopkins university.

mckeown, t. (1976). the modern rise of population. newyork: academic press.

van de walle, e. (1978). "alone in europe, the frenchfertility decline until 1850." in historical studies of changing fertility, ed. c. tilly. princeton, nj: princeton university press.

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other resources

international planned parenthood federation. (2002).available from http://www.ippf.org.

vern l. bullough

Family planning

The exaxt population of the world is unknown but believed at about 6.2 billion; it continues in its unrelenting growth especially in developing countries. Worldwide famine has been postponed thanks to modern agricultural procedures, known as the Green Revolution, which have greatly increased grain production. Nevertheless, with limited land and resources that can be devoted to food production—and increasing numbers of humans who need both space and food—there appears to be a significant risk of catastrophe by overpopulation. Because of this, there is increased interest in family planning. Family planning in this context means birth control to limit family size.

The subject of "family planning" is not limited to birth control but includes procedures designed to overcome difficulties in becoming pregnant. About 15% of couples are unable to conceive children after a year of sexual activity without using birth control. Many couples feel an intense desire and need to conceive children. Aid to these couples is thus a reasonable part of family planning. However, for most discussions of family planning, the emphasis is on limitation of family size, not augmentation.

Birth control procedures have evolved rapidly in this century. Further, utilization of existing procedures is changing with different age groups and different populations. Thus any account of birth control is likely to become rapidly obsolete. An example of the changing technology includes oral contraception with pills containing hormones. Birth control pills have been marketed in the United States since the 1960s. Since that time there have been many formulations with significant reductions in dosage. There was much greater acceptance of pills by American women under the age of 30. The intrauterine device (IUD) was much more popular in Sweden than in the United States whereas sterilization was more common in the United States than in Sweden.

A very common form of birth control is the condom, which is a thin rubber sheath worn by men during sexual intercourse. They are generally readily accessible, cheap, and convenient for those individuals who may not have sexual relations regularly. Sperm cannot penetrate the thin (0.3—0.8 mm thick) latex. Neither the human immunodeficiency virus (HIV) associated with AIDS nor the other pathogenic agents of sexually transmitted diseases (STDs) are able to penetrate the latex barrier. Some individuals are opposed to treating healthy bodies with drugs (hormones) for birth control, and for these individuals, condoms have a special appeal. Natural "skin" (lamb's intestine) condoms are still available for individuals who may be allergic to latex, but this product provides less protection to HIV and other STDs.

The reported failure rate of condoms is high and is most likely due to improper use. Yet during the Great Depression in the 1930s—when pills and other contemporary birth control procedures were not available—it is thought that the proper use of condoms caused the birth rate in the United States to plummet.

Spermicides—surface active agents which inactivate sperm and STD pathogens—can be placed in the vagina in jellies, foam, and suppositories. Condoms used in conjunction with spermicides have a failure rate lower than either method used alone and may provide added protection against some infectious agents.

The vaginal diaphragm, like the condom, is another form of barrier. The diaphragm was in use in World War I and was still used by about one third of couples by the time of World War II. However, because of the efficacy and ease of use of oral contraceptives, and perhaps because of the protection against disease by condoms, the use of vaginal diaphragms is down. The diaphragm, which must be fitted by a physician, is designed to prevent sperm access to the cervix and upper reproductive tract. It is used in conjunction with spermicides. Other similar barriers include the cervical cap and the contraceptive sponge. The cervical cap is smaller than the diaphragm and fits only around that portion of the uterus that protrudes into the vagina. The contraceptive sponge, which contains a spermicide, is inserted into the vagina prior to sexual intercourse and retained for several hours afterwards to insure that no living sperm remain.

Intrauterine devices (IUDs) were popular during the 1960s and 1970s in the United States, but their use today has dwindled. However in China, a nation which is rapidly attending to its population problems, about 60 million women use IUDs. The failure rate of IUDs in less developed countries is reported to be less than that with the pill. The devices may be plastic, copper , or stainless steel. The plastic versions may be impregnated with barium sulfate to permit visualization by x ray and also may slowly release hormones such as progesterone. Ovulation continues with IUD use. Efficacy probably results from a changed uterine environment which kills sperm.

Oral contraception is by means of the "pill." Pills contain an estrogen and a progestational agent, and current dosage is very low compared with several decades ago. The combination of these two agents is taken daily for three weeks followed by one week with neither hormone. Frequently a drug-free pill is taken for the last week to maintain the pill-taking habit and thus enhance the efficacy of the regimen. The estrogenic component prevents follicle maturation, and the progestational component prevents ovulation. Pill-taking women who have multiple sexual partners may wish to consider the addition of a barrier method to minimize risk for STDs. The reliability of the pill reduces the need for abortion or surgical sterilization. There may be other salutary health effects which include less endometrial and ovarian cancer as well as fewer uterine fibroids. Use of oral contraceptives in women over the age of 35 who also smoke is thought to increase the risk of heart and vascular disease.

Contraceptive hormones can be administered by routes other than oral. Subdermal implants of progestin-containing tubules have been available since 1990 in the United States. In this device familiarly known as Norplant, six tubules are surgically placed on the inside of the upper arm, and the hormone diffuses through the wall of the tubules to provide long term contraceptive activity. Another form of progestin-only contraception is by intramuscular injection which must be repeated every three months.

Fears engendered by IUD litigation are thought to have increased the reliance of many American women on surgical sterilization (tubal occlusion). Whatever the reason, more American women rely on the procedure than do their European counterparts. Tubal occlusion involves the mechanical disruption of the oviduct, the tube that leads from the ovary to the uterus, and prevents sperm from reaching the egg. Inasmuch as the fatality rate for the procedure is lower than that of childbirth, surgical sterilization is now the safest method of birth control. Tubal occlusion is far more common now that it was in the 1960s because of the lower cost and reduced surgical stress. Use of the laparoscope and very small incisions into the abdomen have allowed the procedure to be completed during an office visit.

Male sterilization, another method, involves severing the vas deferens, the tube that carries sperm from the testes to the penis. Sperm comprise only a small portion of the ejaculate volume, and thus ejaculation is little changed after vasectomy. The male hormone is produced by the testes and production of that hormone continues as does erection and orgasm.

Most abortions would be unnecessary if proper birth control measures were followed. That of course is not always the case. Legal abortion has become one of the leading surgical procedures in the United States. Morbidity and mortality associated with pregnancy have been reduced more with legal abortion than with any other event since the introduction of antibiotics to fight puerperal fever.

Other methods of birth control are used by individuals who do not wish to use mechanical barriers, devices, or drugs (hormones). One of the oldest of these methods is withdrawal (coitus interruptus ), in which the penis is removed from the vagina just before ejaculation. Withdrawal must be exquisitely timed, is probably frustrating to both partners, is not thought to be reliable, and provides no protection against HIV and other STD infections. Another barrier- and-drug-free procedure is natural family planning (also known as the rhythm method). Abstinence of sexual intercourse is scheduled for a period of time before and after ovulation. Ovulation is calculated by temperature change, careful record keeping of menstruation (the calendar method), or by vaginal mucous inspection. Natural family planning has appeal for individuals who wish to limit their exposure to drugs, but it provides no protection against HIV and other STDs.

The population of the world increases by about 140 million every year, while the world is unable to sustain its new residents adequately. That increase signals the need for family planning education and the continued development of ever more efficient birth control methods.

See also Population Council; Population growth; Population Institute

[Robert G. McKinnell ]

RESOURCES

BOOKS

Sitruk-Ware, R., and C. W. Bardin. Contraception. New York: Marcel Dekker, 1992.

Speroff, L., and P. D. Darney. A Clinical Guide for Contraception. Baltimore: Williams & Wilkins, 1992.