Chapter 11: Human Reproduction
Contemporary American couples are planning to have an average of between two and three children. Given the fact of youthful marriage, far-from-perfect means of fertility control, and varying motivation, many of these couples will have children before they want them and a significant fraction will ultimately exceed the number they want.
Recent research’ has disclosed a substantial incidence of such unplanned pregnancies and unwanted births in the United States. According to estimates developed in the 1970 National Fertility Study conducted by the Office of Population Research at Princeton University, 44 percent of all births to currently married women during the five years between 1966 and 1970 were unplanned; 15 percent were reported by the parents as having never been wanted. (See Table 11.1.) Only one percent of first births were never wanted, but nearly two-thirds of all sixth or higher order births were so reported. In theory, this incidence of unwanted births implies that 2.65 million births occurring in that five-year period would never have occurred had the complete availability of perfect fertility control permitted couples to realize their preferences. And these estimates are all conservative.
Unwanted fertility is highest among those whose levels of education and income are lowest. For example, in 1970, women with no high-school education reported that 31 percent of their births in the preceding five years were unwanted at the time they were conceived; the figure for women college graduates was seven percent. Mainly because of differences in education and income—and a general exclusion from the socioeconomic mainstream—unwanted fertility weighs most heavily on certain minority groups in our population. We have relevant data for blacks only, but this is probably true for Mexican-Americans, Puerto Ricans, Indians, and others as well.
For example, if blacks could have the number of children they want and no more, their fertility and that of the majority white population would be very similar. These figures about our black population illustrate the inequality of access of our minority populations to the various means of fertility control, as well as to the education and income which is so closely connected with that access.
Not all unwanted births become unwanted children. Many, perhaps most, are eventually accepted and loved indistinguishably from earlier births that were deliberately planned. But many are not; and the costs to them, to their siblings and parents, and to society at urge are considerable, though not easy to measure.
Table 11.1 Unwanted Fertility in the United States, 1 970a
aBased on data from the 1970 National Fertility Study for currently married women under 45 years of age.
bUnplanned births include unwanted births.
And the costs are not only financial. The social, health, and psychological costs must be enormous. Despite the incidence of unwanted fertility—an incidence which in terms of ordinary public health criteria would qualify as of epidemic proportion—there is little hard evidence on which to assess its impact. There was one study in Sweden2 in which a sample of children born to women whose applications for abortion were denied, was compared over a 20-year period with a control group of other children born at the same time in the same hospital. They turned out to have been registered more often with psychiatric services, engaged in more antisocial and criminal behavior, and have been more dependent on public assistance.
The psychological burdens carried by children who are literally rejected by their parents and given over to institutional care cannot be measured easily. But they must be considerable, and we do know that the costs to society of providing for the care of abandoned infants are significant.
Most of the costs of unwanted fertility are not visible in the dramatic instances of abandonment or child abuse, but rather in the more prosaic problems of everyday family life. Family budgets can be seriously strained by the unexpected and unwanted birth of a child. And those who can least afford such additional burdens most often experience them. The incidence of unwanted births is twice as great among couples whose annual incomes fall below $4,000 as it is among those with incomes of $10,000 and higher. Since most unwanted births experienced by married couples occur late in the childbearing years, the woman who had been waiting for her youngest child to be in school before returning to work can find her plans abruptly frustrated.
There are also health costs involved. As President Nixon observed:
involuntary childbearing often results in poor physical and emotional health for all members of the family. It is one of the factors which contributes to our distressingly high infant mortality, the unacceptable level of malnutrition.. 3
These health problems result, in part, from the fact that most unwanted births occur to women in the later years of childbearing. And these are the ages at which there are considerably greater risks to maternity. For example, although maternal mortality has declined by 94 percent over the past 30 years to a rate of 24 maternal deaths per 100,000 live births, the risks increase sharply at the older ages. Compared with the rate at age 20 to 24 when the risk is lowest, the rate is four times greater at ages 35 to 39, almost eight times greater at ages 40 to 44, and nearly 20 times greater at older ages.4
The risk to the infant’s life is also associated with the mother’s age; the infant mortality rate runs almost one-third higher among women 35 years of age and over, than among women aged 20 to 24.5
Because of the strong association between maternal age and the appearance of certain hereditary diseases, the prevention of births to women over 35 would reduce the incidence of such diseases. For example, the incidence of Down’s syndrome, which accounts for 95 percent of mongolism, would be reduced significantly by the avoidance of childbearing in the older ages.
How far down the road toward population stabilization would the prevention of unwanted births take us? Since fertility has been changing so rapidly in recent years, such an estimate is difficult to make. The record of women who are approaching the end of their childbearing, those 35 to 44 years old in 1970, indicates that 27 percent had at least one unwanted birth, a total of one in every six births. The prevention of the unwanted births in this group would have carried them about three-fifths of the way to the replacement level. But women in those age groups were the main participants in the post-war baby boom and have had the 1 highest fertility of any women in modern time. And there has been a significant change downward in the family-size expectations of young couples.
We conclude that there are many “costs” associated with unwanted fertility, not only financial, but health, social, psychological, and demographic costs as well.
The Commission believes that all Americans, regardless of age, marital status, or income, should be enabled to avoid unwanted births. Major efforts should be made to enlarge and improve the opportunity for individuals to control their own fertility, aiming toward the development of a basic ethical principle that only wanted children are brought into the world.
In order to implement this policy, the Commission has formulated the following recommendations that are developed in detail in the remainder of this chapter:
The elimination of legal restrictions on access to contraceptive information and services, and the development by the states of affirmative legislation to permit minors to receive such information and services.
The elimination of administrative restrictions on access to voluntary contraceptive sterilization.
The liberalization of state abortion laws along the lines of the New York State statute.
Greater investments in research and development of improved methods of contraception.
Full support of all health services related to fertility, programs to improve training for and delivery of these services, an extension of government family planning project grant programs, and the development of a program of family planning education.
Contraception and the Law
After almost a century of innumerable efforts on the part of many individuals and agencies, Congress finally, on January 8, 1971, repealed the 1873 Comstock Act—a broad gauge obscenity law which had prohibited in its omnibus sweep the importation, transportation in interstate commerce, and mailing of “any article whatever for the prevention of conception.” Thus, the anti-contraception law of the federal government is now substantially limited to unsolicited contraceptives and unsolicited contraceptive advertising.6
The states, too, have considerably modified their “little Comstock laws,” so that today contraception is legal for adults in all states (with the possible exception of Massachusetts and Wisconsin, which specify that the adults must be married). However, more than half the states retain, in effect, statutes which prohibit or restrict the sale, distribution, advertising, and display of contraceptives.
Approximately 22 states prohibit the sale of all or some contraceptives; but all states, either by statute or common law, allow exceptions for doctors, pharmacists, or other licensed firms or individuals. Roughly 23 states prohibit commercial advertising of contraceptives, but most of these states make exceptions for medical and pharmaceutical journals.
The same 23 states also condemn the display of contraceptives and of information about them, but, with a few possible exceptions, explicitly permit such display under certain circumstances. At least 27 states, either expressly or inferentially, prohibit the sale of contraceptives through vending machines.
Literal interpretations of these anti-birth control laws are often unreliable; their enforcement is uneven, and in some instances, there are conflicting interpretations. In several states, court decisions have modified or even nullified the letter of the statute.
Some attacks on the statutes have been successful, but court decisions are much less visible than statutes. Clearly, the statutes themselves should be clarified or, better still, repealed.
One way or another, these laws inhibit family planning education, as well as family planning programs, and/or impinge on the ready availability of methods of contraception to the public. By prohibiting commercial sales, advertising displays, and the use of vending machines for nonprescription contraceptives, they sacrifice accessibility, education, and individual rights in the interest of some undefined purpose. Whatever the original justification for these laws, their result is to prevent contraceptive information and supplies from being easily obtainable in general and, in some instances, make them unobtainable.
Merely removing such laws will not automatically ensure freedom of access and choice. More is needed in the way of affirmative programs to distribute such information and supplies to all who may wish to use them. Nonetheless, it is desirable and important that laws not operate as impediments.
The Commission thus recommends that: (1) states eliminate existing legal inhibitions and restrictions on access to contraceptive information, procedures, and supplies; and (2) states develop statutes affirming the desirability that all persons have ready and practicable access to contraceptive information, procedures, and supplies.
Legal Impediments for Minors
It seems clear that the law also plays a role in the inadequate access of teenagers to contraceptive information and services.* The laws here are not so much the laws on contraception, but the inchoate and never universally applicable common law rule which has been considered to bar medical treatment and examination of minors without parental consent. Although it has been assumed that this was the rule at common law, the fact is that there were always many exceptions recognized by the same common law, some of which seem to sanction contraceptive services to teenagers—for example, in emergencies or when the minor was married or otherwise “emancipated.” Recently, the courts, including the United States Supreme Court, have held that minors are not second class citizens and that they are entitled to constitutional rights of many kinds. Arguably, one of these rights is the right to decide whether or not to have a child.
In addition, some state courts have declared the existence of a further exception to the common law rule which has since become known as the “mature minor rule.” In essence, it provides that a minor may consent to medical treatment for himself if he understands the nature of the treatment and it is for his benefit.
Notwithstanding the fact that there appears to be no case on record of a successful suit against a doctor or a health agency for rendering any kind of medical service to a minor over 15 without parental consent, the uncertainty and ambiguity in the general law governing medical services to minors has inevitably restricted access to contraceptive services. Many physicians are reluctant to prescribe contraceptives even for sexually active minors who have been, or who clearly will be, exposed to the risks of pregnancy. Despite the absence of prosecutions and civil suits, physicians continue to fear that action will be taken against them.
*Separate statements by Commissioners Paul B. Cornely, M.D. (p. 148), Alan Cranston (p. 151), and John N. Erlenborn (p. 156) appear on the indicated pages.
Faced with this reluctance on the part of the medical and related professions, an ever-increasing number of states have enacted new laws to permit minors to consent to medical services in general, or in such areas as birth control, venereal disease, and drugs. Nevertheless, it is clear that many of the new statutes do not cover thousands of single minors—those who are not yet parents, who want to postpone becoming such, who are living with their families, who prefer to stay in school, or who are not managing their own financial affairs. Even some of those state laws which authorize family planning programs impose, specifically or in practice, such eligibility requirements as parenthood or marriage, 18 years of age and married, or marriage or parental consent.
Medical and agency practices tend to be restrictive and discriminatory against minors in the absence of a clear mandate for full availability from the legislature. A number of major United States medical organizations have made recommendations approaching the recent statement of the Executive Board of the American College of Obstetricians and Gynecologists which declared:
The never married, never pregnant, sexually-involved female has not yet been reached with effective contraception. The laws of some states indirectly prohibit this service to minors and thereby prevent the gynecologists from serving them or place the physician in legal jeopardy if he does so.7
The Board went on to state that “the unmarried female of any age should have access to the most effective methods of contraception,” and urged that legal barriers which restrict the physician’s freedom should be removed “even in the case of the unemancipated minor who refuses to involve her parents.”
Because of the serious social and health consequences involved in teenage pregnancy and the high rates of teenage out-of-wedlock pregnancy and venereal disease, the Commission urges the elimination of legal restrictions on access to contraceptive and prophylactic information and services by young people.
We recommend that states adopt affirmative legislation which will permit minors to receive contraceptive and prophylactic information and services in appropriate settings sensitive to their needs and concerns.
To implement this policy, the Commission urges that organizations, such as the Council on State Governments, the American Law Institute, and the American Bar Association, formulate appropriate model statutes.
Given the difficulties experienced by many women with the pill and the intrauterine device, and the high failure rates of many other methods of contraception currently used, an increasing proportion of persons are turning to surgical sterilization.8 According to the 1970 National Fertility Study, sterilization has become a very popular method of preventing conception. Almost three million wives under the age of 45, or their husbands, had elected sterilization for contraceptive reasons. This amounts to nearly one in every five couples able to bear children who do not intend to have any more. About half of such operations are elected by women and half by men. Between 1966 and 1970, the typical case was a woman of 32 or a man of 35 with an average of nearly four children.
The average fecund woman, after the birth of her last wanted child, has some 10 or 15 years of exposure to the risk of an unwanted conception before the onset of menopause, and current patterns of contraceptive use offer little confidence. Elective sterilization—tubal ligation for females and vasectomy for males—offers many couples secure protection against involuntary pregnancy. The former requires a 15-minute operation in which the fallopian tubes are tied off and several days hospitalization; the vasectomy, typically performed in a doctor’s office in a few minutes, involves cutting and tying the vas deferens tubes which carry the sperm, a procedure which, contrary to some misunderstanding, has no significance for sexual behavior. A new procedure for women—laproscopic/culdoscopic sterilization—has also been developed. This procedure requires no hospitalization. And research on reversibility of male and female sterilization is under way. New developments in the male procedure offer the possibility of substantially increasing the probability of reversal; and the existence of sperm banks greatly modifies the major concern about possible changes of mind in the future.
The legal situation with respect to voluntary sterilization is quite different than with contraception or abortion. There is no general federal law governing voluntary sterilization, and the few existing state laws. by and large, present no insuperable problems. Rather, the lack of any specific law in many states often leaves physicians in a climate of uncertainty where many fear civil or criminal liability for performing voluntary sterilizations, even though, under well-settled principles of law, what is not prohibited is permitted.
Apart from the vagueness of the statutory situation, many hospitals impose various requirements for voluntary sterilization which greatly cut down on its availability. Such requirements include limiting the procedure to persons of specified age and number of children, or permitting only therapeutic as opposed to contraceptive sterilizations.
In order to permit freedom of choice, the Commission recommends that all administrative restrictions on access to voluntary contraceptive sterilization be eliminated so that the decision be made solely by physician and patient.
To implement this policy, we recommend that national hospital and medical associations, and their state chapters, promote the removal of existing restrictions.
Prior to the second quarter of the 19th century, the law applicable to abortion in the American colonies, and subsequently in the expanding United States, was the Common Law of England. Under that law, women were free to have abortions at least until “quickening”— the first perception of fetal movement by the pregnant woman, which usually occurs between the 16th and 20th week.9
In the second quarter of the 19th century, restrictive laws were enacted in 12 states. The only known contemporary authoritative texts explaining the reason for the enactment of these prohibitions of abortion before “quickening” relate to New York and New Jersey. Both point to the life and health of the pregnant woman as considerations. Before the introduction of ether anesthesia (1846) and antisepsis (1867), any surgery was likely to cause death from shock or infection. Actually, at the time New York State adopted such restrictive laws in 1829, serious consideration was given to banning all surgical operations except when necessary for the preservation of life. Thus, in the drafting of such legislation, the concern of the lawmakers was medical as well as moral. It was in the latter half of the century that the sensationalism of Anthony Comstock inspired a moral fervor which resulted in moral considerations becoming the dominant element in highly stringent laws against abortion.
Currently, in over two-thirds of the states, abortion is a crime except to preserve the life of the mother; 12 states have changed their abortion statutes consistent with the American Law Institute Model Penal Code provision on abortion which prohibits abortion except in cases where the mother’s life or her mental or physical health is in danger, or to prevent the birth of defective offspring, or in cases of rape or incest. In 1970, abortion laws in Alaska, Hawaii, and New York were liberalized by law and in the state of Washington by popular referendum. Currently, abortion is being reviewed in the courts in over half of the states.
At its 1972 meeting, the House of Delegates of the American Bar Association approved a Uniform Abortion Act recommended by the Commissioners on Uniform State Laws stating that abortion may be performed by a duly licensed physician upon request.
The Moral Question
The Commission recognizes that abortion is a complex issue requiring a thoughtful balancing of moral, personal, and social values.10 As the Commission moves toward a population policy for the United States, our principal objective is the enrichment of life, not its restriction. We share with our fellow citizens an abiding concern for the sanctity of all human life. Thus, we appreciate the moral decisions involved in abortion, as well as the possible insensitivity to all human life implied in the practice of abortion. It is from this perspective that we have approached three moral issues concerning abortion which we believe to be of foremost importance.
The first issue relates to the fetus, both as to the termination of potential life and determining when that life actually begins. The second relates to bringing into the world an unwanted child, particularly when the child’s prospects for a life of dignity and self-fulfillment are limited. Third, there is the question of the woman who in desperation seeks an abortion. Our society faces a difficult decision when the woman believes her well-being is threatened and she sees no other way out but an illegal abortion with all its attendant dangers.
The Commission believes that a wise and sound decision in regard to the abortion question requires a careful balancing of the moral problems relating to the woman and the child along with those concerning the fetus.
In the development of western culture, the tendency has been toward a greater protection of life. At the same time, there is a deep commitment in our moral tradition to individual freedom and social justice. The Commission believes that the various prohibitions against abortion throughout the United States stand as obstacles to the exercise of individual freedom: the freedom of women to make difficult moral choices based on their personal values, the freedom of women to control their own fertility, and finally, freedom from the burdens of unwanted childbearing. Restrictive statutes also violate social justice, for when abortion is prohibited, women resort to illegal abortions to prevent unwanted births. Medically safe abortions have always been available to the wealthy, to those who could afford the high costs of physicians and trips abroad; but the poor woman has been forced to risk her life and health with folk remedies and disreputable practitioners.
Abortion is not new; it has been an alternative to an unwanted birth for large numbers of American women (estimates ranged from 200,000 to 1,200,000 illegal abortions per year in the United States). The Commission regards the issue of illegal abortion with great concern and supports measures to bring this medical procedure from the backrooms to the hospitals and clinics of this country. It is becoming increasingly clear that, where abortion is available on request, one result is a reduction in the number of illegal abortions. Deaths as a consequence of illegal abortion have dropped sharply in New York since the enactment of a liberal abortion statute.” The number of women admitted to New York City hospitals with incomplete abortions has also declined. The experience in California is comparable; the number of maternal deaths has decreased as the number of therapeutic abortions has increased. Comparative data from Czechoslovakia, Hungary, and Poland also indicate that, after liberalization of abortion laws in the 1950’s, hospital admissions for “other” abortions declined.
A reduction in the number of illegal abortions has an important impact on maternal mortality. Maternal mortality ratios (including the 12 deaths out of 278,122 abortions performed under legal auspices) in New York City dropped by two-thirds the year after abortion became available on request. For 1971, New York City experienced the lowest ratio of maternal deaths ever recorded. Judging from the experience in other countries, there is reason to suspect that the maternal death ratio will continue to decline. The most important variables in mortality from abortion are the length of gestation and the technique involved. The greatest number of complications occur after the 14th week of gestation. In New York, abortions performed before 12 weeks have a complication rate of 4.6 per 1,000 abortions; for those after 12 weeks, the rate is 26.8 per ‘1,000. The safety record will undoubtedly improve as physicians and institutions gain more experience with the procedure, and as the proportion of first trimester abortions increases. The choice of the technique for performing an abortion is largely determined by the period of gestation. As the number of early abortions increase so will the use of the safest known technique— suction curettage.
In his testimony before the Commission, Gordon Chase, New York City Health Services Administrator, reviewed the impact of abortion on request on infant mortality:
For example, infant mortality, which has been dropping in the City, has apparently been further reduced by abortion “on demand.” This is because the procedure is now broadly available to those women who are at greatest risk of giving birth to infants who may die: namely, very young women, unwed mothers, who generally get poorer pre-natal care, and women who have had many previous births and pregnancies, as well as women with medical handicaps. For 1969, infant mortality was 24.4 per 1,000 live births; it was down to 21.6 for 1970; and down still further to 20.7 in 1971, the first year in which the law would have had an impact. Neo-natal mortality—deaths occurring in the first 28 days of life—shows a more striking decline: from 18.1 to 16.2 to 14.9 in the past three years. 12
What is the effect of abortion on out-of-wedlock births? The best information comes from New York, where out-of-wedlock births have been on the rise since they were first recorded in 1954. Statistics for the first eight months of 1971 indicate that, for the first time, the rate is declining. Moreover, the New York City programs for unmarried pregnant girls have reported a sharp decline in the number of applicants this year.
In summary, we are impressed that the availability of abortion on request causes a reduction in the number of illegal abortions, maternal and infant deaths, and out-of-wedlock births, thereby greatly improving the health of women and children.
The Commission affirms that contraception is the method of choice for preventing an unwanted birth. We believe that abortion should not be considered a substitute for birth control, but rather as one element in a comprehensive system of maternal and infant health care. For many, the very need for abortion is evidence of a social and personal failure in the provision and use of birth control. In the year beginning July 1, 170, an estimated 505,000 legal abortions and an unknown number of illegal abortions were performed in the United States. 13 Far too many Americans must resort to abortion to prevent an unwanted birth. It is our belief that the responsible use of birth control can be achieved only when sex counseling and contraceptive information and services are easily accessible to all citizens.
The Commission expects that, with the increasing availability of contraceptives and improvements in contraceptive technology, the need for abortion will diminish. It is encouraging to learn that there has been a marked increase in recent attendance in family planning programs in New York City.
The Demographic Context
In reviewing the abortion issue, one central concern has been an evaluation of the demographic impact of abortion. We appreciate the historic importance of placing recommendations on abortion in a demographic context.
At the present time, it is difficult to make precise quantitative statements concerning the demographic impact of abortion. We are unable to estimate the effect on the birthrate of an unknown number of illegal abortions. There is little doubt, however, that legal and illegal abortions exert a downward influence on the United States birthrate. Support for this general conclusion is found in the preliminary data from New York and the experiences of some other nations with liberal abortion policies, notably Japan and the Eastern European countries.14 However, caution must be exercised in generalizing from the experience of other countries to the impact of abortion on United States population growth. The United States differs from these other nations socially, politically, economically, and most importantly, in the level of contraceptive practice.
Only limited data on the demographic consequences of abortion are available from New York. Our best estimate of the probable impact if the entire country were to follow the New York law would be a decline of 1.5 per 1,000 in the birthrate in the first year after restrictions were removed.15
Public opinion on abortion is changing, tending recently to grow more liberal. Some 14 to 20 percent more women in 1970 than in 1965 approve of abortion for various reasons, according to interview data collected in the 1965 and 1970 National Fertility Studies.16 The public opinion survey conducted in 1971 for the Commission indicates that half of all Americans believe that abortion should be a matter decided solely between individuals and their physicians; an additional 41 percent would permit abortion under certain circumstances, and six percent flatly oppose abortions under any circumstances. Estimates of the current state of attitudes on abortion doubtless depend very much on the phrasing of the question and the interpretation of the respondent.
In general, support for increasing the availability of legal abortions is strongest among non-Catholics and among those who are well-educated. Among the general public, 38 percent feel that the government should help make abortion available to all women who want it.17
The abortion issue raises a great number of moral, legal, public health, and demographic concerns. As a group, the Commission has carefully considered these issues, and based on their personal views, individual members of the Commission have resolved these questions differently .*
A few members of the Commission** are opposed to abortion. These Commissioners consider abortion a remedial measure, and choose to emphasize society’s responsibility for improving and enriching the lives of all citizens.
Some Commissioners*** approve of abortion only under the specific conditions set forth in the American Law Institute model abortion statute. These Commissioners believe that no woman should be forced to bear a child, thereby endangering her physical or mental health. Their concern is that abortion be available only on a limited basis and that it be considered as a last resort to protect life or health.
The majority of the Commission believes that women should be free to determine their own fertility, that the matter of abortion should be left to the conscience of the individual concerned, in consultation with her physician, and that states should be encouraged to enact affirmative statutes creating a clear and positive framework for the practice of abortion on request.
*Separate statements by Commissioners Alan Cranston (p. 151) and John N. Erlenborn (p. 156) appear on the indicated pages.
**Separate statements by Commissioners Paul B. Cornely, M.D. (p. 148) and Grace Olivarez (p. 160) appear on the indicated pages.
***A separate statement by Commissioner Marilyn Brant Chandler appears on page 148.
Therefore, with the admonition that abortion not be considered a primary means of fertility control, the Commission recommends that present state laws restricting abortion be liberalized along the lines of the New York State statute, such abortions to be performed on request by duly licensed physicians under conditions of medical safety.
In carrying out this policy, the Commission recommends:
That federal, state, and local governments make funds available to support abortion services in states with liberalized statutes.
That abortion be specifically included in comprehensive health insurance benefits, both public and private.
Methods of Fertility Control
Although current knowledge, if applied systematically, could bring about considerable progress toward reducing unwanted fertility, the successful control of reproduction depends greatly on the availability of efficient methods for regulation of fertility.*
*Separate statements by Commissioners John N. Erlenborn (p. 157) and George D. Woods (p. 169) appear on the indicated pages.
The development of the pill and the intrauterine device represent major innovations in contraceptive technology, but they are far from perfect solutions to the problem of control of reproduction. We must have contraceptives and other methods of fertility control that are safe and free of any adverse reactions; effective, acceptable, coitus independent, and accessible commercially rather than medically; and inexpensive, easy to use, and reversible. This goal will be reached only if research efforts equal the magnitude of the task.
Currently, some new approaches to fertility control are in experimental trial; other possibilities are under laboratory investigation.18 The list of potentialities includes daily pills for women that would be safer than those now available; weekly or monthly pills for men or women; a small plastic implant to be placed under the skin of men or women that could last for years; sophisticated devices or procedures that would make voluntary sterilization of either men or women safer, simpler, and more reversible; modern forms of intrauterine or intravaginal devices that women could use safely in a variety of ways depending on their own preferences; natural substances that could regularize menstrual cycles and improve the rhythm method; and natural substances for post-coital use which interfere with the development of pregnancy. Thus, prospects exist for developing new methods of fertility control which could have advantages over those currently available. However, none of these contain all of the elements of the “perfect” contraceptive.
Until a dozen years ago, all major methods of contraception were based on the simple principle of preventing the sperm and egg from meeting in the fallopian tube, where fertilization occurs. The rhythm method of contraception was the first attempt at fertility control based on the understanding of the endocrinological aspects of the ovarian cycle and the limited duration of egg survival. The pill and the intrauterine device further exploited this knowledge and represented significant breakthroughs in a field which has been largely neglected by science for most of human history. However, in terms of the potential technology which should be feasible as a result of today’s sophisticated scientific capabilities, the contraceptive methods currently available are fairly primitive.
Other methods of fertility control are far from perfect. Voluntary sterilization is increasing in popularity; and new procedures are being tried, but progress is slow. There is widespread resort to abortion in the United States and throughout the world. In the last decade, new techniques have emerged which are simpler and less traumatic; but they are expensive and need further refinement.
Methods of fertility regulation remain limited because our knowledge of basic reproductive biology is inadequate. We do not fully understand what governs ovulation, how long an ovum can survive, what governs sperm production, how long sperm survive, what governs a menstrual cycle, or how long it lasts. Such knowledge is essential for the practice of “rhythm” as well as for effective chemical or mechanical contraception. Unwanted and accidental pregnancies are only one consequence of our ignorance. Many couples avoid pregnancy only through use of methods that are cumbersome and produce a great deal of anxiety. Others who desperately want children cannot conceive. A large number of married couples suffer from problems of infertility; the ability to help them is sorely limited by the same lack of information concerning basic reproductive processes that inhibits effective contraception.
This knowledge is essential, not just for regulating fertility, but also for improving the outcome of pregnancy. Today, many mothers suffer the risk of serious injury, ill health or even death in pregnancy and childbirth. Too many children are born with physical and mental handicaps. We spend billions in therapy, remedial treatment, custodial care, and repair of damage that might have been prevented by a more complete understanding of the factors governing reproduction.
Whether the interest is in conception or contraception, in chemical or mechanical contraception or in rhythm, in genetic counseling or mental retardation or cerebral palsy, the basic knowledge necessary is largely the same. There must be an understanding of the role and functioning of the ovary and the testes, of the egg and the sperm, of the process of fertilization itself, and the normal course of gestation. This is knowledge we do not have and must attain.
Any overall strategy for the development of new agents or methods of fertility control must include not only basic research in the biology of reproduction, but also clinical trials, and related toxicological investigations, the development of new products and techniques, and the continuing evaluation of new methods with regard to both effectiveness and short-term and long-term safety. It is essential, too, that extensive, critical evaluation be made of the total effects of existing methods of contraception.
The limited amount of usable knowledge of human reproduction and fertility control is the result of the lack of interest we have had in this by comparison with other scientific and technological fields. As Secretary Richardson acknowledged in the Department of Health, Education and Welfare Five-Year Plan for Family Planning Services and Population Research:
in spite of its transcendent importance to human existence, reproduction has received relatively little scientific attention. Even with today’s concern for the population problem, the most talented among young investigators all too frequently seek other subjects.’9
It is not difficult to understand why this has been the case. Career choices are largely shaped by the priorities that public and private institutions set when they allocate their resources. During the past two decades, as government support for science has mushroomed, the role of government in setting scientific priorities has become decisive. Our scientists have been responsive to these priorities, creating entirely new scientific subcommunities, where none previously existed—in defense, space, and favored areas of medical research.
Beginning a quarter of a century ago with the formation of a committee on human reproduction by the National Research Council, there have been several efforts to stimulate greater interest in fertility research. This issue has been placed before the nation by scientists and citizens with impeccable credentials. The results of these efforts have not come close to the commitment required.
For too long, fertility control was viewed as an unacceptable subject for public concern; private resources were required to lead the way in supporting research in this field. Pharmaceutical companies have supported a large portion of contraceptive research. One incomplete survey showed that their cumulative expenditure from 1965 through 1969 amounted to $68 million.20 It is unrealistic to rely primarily upon those companies to do the necessary research in this field. Pharmaceutical companies cannot be expected to continue to invest heavily in research unless they can expect a profit from it. Some of the kinds of contraceptives needed may not offer prospects of profits.
A few private foundations have contributed a large share of the money spent in reproductive research, providing over 60 percent of all of nonindustry funds expended in 1969. However, only five percent of all private funds spent on medical research went to the population field, and it is unlikely that the foundation investment will increase substantially.21
Presidents Kennedy, Johnson, and Nixon all expressed support for increased governmental funding of fertility-related research. The Congress has authorized up to $93 million for population research in fiscal year 1973.22 Both President Johnson’s Committee on Population and Family Planning, and a committee of experts appointed to advise the Secretary of Health, Education and Welfare on the scope of research needs, urged federal expenditures of at least $100 million; and the latter group recommended that the total federal expenditure rise to $250 million by fiscal year 1974. 23 The Five-Year Plan for Family Planning Services and Population Research, drawn up by the Department of Health, Education and Welfare, is based upon a federal expenditure in fiscal year 1973 of $75 million.24 These amounts are modest in terms of society’s total research expenditures. They are modest in terms of the federal government’s research expenditures, but they are far above the total amounts requested and approved for population research. The budget for fiscal year 1973 includes only $44.8 million for this purpose—less than half of the amount authorized and only $5.5 million more than in the previous fiscal year. This amount is far too small for a task which is crucial both in dealing with the population problem and in improving the outcome of pregnancy for women and children. It is essential to increase support for both biomedical and behavioral research related to fertility.
Support for research and training in the basic science of reproduction alone requires at least $100 million in federal funds annually. An additional $100 million annually is required for developmental work on methods of fertility control.25 Although a larger component of support may be expected from nongovernmental sources for some aspects of product development, the federal government must still provide the major portion of the funding. In addition, at least $50 million a year in federal funds are needed for social and behavioral research which is discussed further in Chapter 15.
An important step in helping people throughout the world to control their fertility more successfully is the development of better methods of fertility control. The need is urgent, and we would like to see all of the required funds for research in this field become available immediately. However, it seems clear that the capacity does not currently exist within the federal government to administer effectively such an expansion. We believe this capacity should be developed as soon as possible; we speak to this issue in some detail in our organizational recommendations in Chapter 16.
The Commission recommends that this nation give the highest priority to research reproductive biology and to the search for improved methods by which individuals can control their own fertility.
In order to carry out this research, the Commission recommends that the full $93 million authorized for this purpose in fiscal year 1973 be appropriated and allocated; that federal expenditures for these purposes rise to a minimum of $150 million by 1975; and that private organizations continue and expand their work in this field.
The justification for a national policy and program to reduce unwanted pregnancy is independent of its demographic significance.* From both individual and societal viewpoints, the reduction of unwanted fertility is a highly desirable goal for many other reasons. We have seen that unwanted and accidental pregnancies are associated with serious health, social, and economic consequences. Many couples have learned to cope with these consequences, but they hardly contribute to an improved quality of life for them or their children.
*Separate statements by Commissioners John N. Erienborn (p. 157) and George D. Woods (p. 169) appear on the indicated pages.
Couples in all socioeconomic groups experience unwanted pregnancies, but they occur most often and have the most serious consequences among low-income couples. Middle-income groups have generally relied upon private physicians for family planning services. Access to these services among lower-income persons, who do not have private physicians, has been severely limited. Until very recently, only private organizations, such as Planned Parenthood, and a few local and state health departments, attempted to provide these services to low-income individuals. However, recognizing the personal, economic, and health benefits of reducing unwanted pregnancy, the federal government, since 1967, has been striving to increase the availability of family planning through a program of subsidized services. The response to the federal family planning program has borne out the contention that there is a need for family planning methods among many low-income people, that this need is perceived, and that individuals will voluntarily use fertility control services if these are offered in a manner and setting that are dignified and humane.
The project grant programs, carried out by the National Center for Family Planning Services of the Department of Health, Education and Welfare and the Office of Economic Opportunity, have been the principal components of the increased federal effort. With a relatively modest federal investment, organized family planning programs have succeeded in introducing modern family planning services to nearly 40 percent of low-income persons in need.26 The majority of those in need remain unserved, however, and the number of hospitals, health departments, and voluntary agencies not providing services remains substantial. No organized services have been reported in half of all counties in the country. While P.L. 91-572, the Family Planning Services and Population Research Act, has increased the federal authorization for support of family planning services, existing authorizations account for less than half of the funds required. The five-year plan, prepared in accordance with P.L. 91-572, makes clear that the delivery of services to those who need and want them is feasible and within the capabilities of our existing health system.27 The achievement of this objective will clearly require additional federal authorizations and appropriations as well as increased support for these programs from state and local governments, and from private philanthropy. It is essential that the current federal program be expanded, strengthened, and provided with the resources necessary to complete its mission.
If family planning services are maximally to assist couples in avoiding the dependency caused by unwanted fertility, the program cannot be limited only to those persons already classified as poor. We are therefore puzzled—and concerned—that the definition of low income embodied in the regulations proposed for the present federal family planning program is set at $4,200 per annum.28 Public health programs have traditionally been designed to serve all persons who choose to avail themselves of these services; to select family planning services as a major departure from this policy has grave implications. We urge that no means test be applied in the administration of these programs. Their purpose must be to enlarge personal freedom for all, not to restrict its benefits only to the poorest of the poor.
While the current family planning program, which provides services to low-income persons, is justified on the basis of acute need within this group, unwanted pregnancies occur in all segments of our society; there are many nonpoor individuals who need but who do not receive adequate fertility control services.
Fertility-Related Health Services
Most Americans secure their health services through private physicians. Yet studies show that most physicians do not perceive it to be their function to actively provide fertility control services.
In part, this is because of the taboos that have historically surrounded fertility control. But it is also a result of the fact that our medical system primarily emphasizes curative medicine and acute, catastrophic care rather than preventive medicine. For this reason, it is not just fertility-control services that are inadequately provided, but the whole range of fertility-related services including maternity and infant care.
Very few current private or public health financing mechanisms pay for such items as office visits, drugs, and laboratory tests—the principal elements of contraceptive services. One insurance company declined to pay for the cost of inserting an intrauterine device on the grounds that such a procedure does not “represent necessary medical care and treatment.” Costs of surgical procedures such as abortion and sterilization are covered inadequately, if at all.
With our growing recognition of the vital importance of adequate prenatal and infant care, it is regrettable that only a fraction of the costs of these services are defrayed by health financing mechanisms. Future generations of Americans should be born wanted by their parents, brought into the world with the best skills that modern medicine can offer, and provided with the love and care necessary for a healthy and productive life.
The Commission recommends a national policy and voluntary program to reduce unwanted fertility, to improve the outcome of pregnancy, and to improve the health of children.
In order to carry out such a program, public and private health financing mechanisms should begin paying the full cost of all health services related to fertility, including contraceptive, prenatal, delivery, and postpartum services; pediatric care for the first year of life; voluntary sterilization; safe termination of unwanted pregnancy; and medical treatment of infertility.
Estimates have been made of the costs to American society of such a program.29 At current fees and institutional charges, the entire gamut of services for all who would require them, regardless of age, marital status, or income, is estimated to cost from $6.7 to $8.1 billion annually in the next five years. More than 70 percent of this cost would cover maternity and pediatric care, while the balance constitutes the total cost of voluntary fertility control. Individuals, public and private third-party mechanisms, and public health programs already finance all but about $1 billion of this total cost. But many persons do not receive all or some of these critical fertility-related health services as a result of inadequate insurance coverage, lack of income, differential access to medical resources, and inadequate public and private programs.
To place this concept in perspective, it is useful to note that total United States health expenditures in fiscal year 1971 are estimated at $75 billion, and our gross national product at more than $1 trillion. The cost to our society of paying for all necessary modern medical care related to the bearing of healthy, wanted children thus would constitute nine percent of our national health bill, and less than 0.7 percent of GNP. On a per capita basis, the total annual cost of such a comprehensive program would be $32 to $34. In fiscal year 1971, per capita health expenditures of all types totaled $358.
These estimates do not, in fact, represent a true “cost” to our society. The expenditure of these sums for adequate fertility-related medical care would, in all probability, be more than offset by the benefits to individuals and society of the delivery of healthy children and the prevention of unwanted pregnancies. One-fourth of the expenditures for the fertility-control services (as distinguished from maternity and pediatric care) would, in fact, be quickly offset by the elimination of the costs of prenatal, delivery, and postnatal care resulting from unwanted pregnancies and births.
The financing of all health services related to fertility control could easily be integrated into current publicly administered health financing systems, and made part of a new comprehensive national health insurance system. Congress should include this coverage in any health insurance system it adopts.
We wish to point out, however, that its initiation is not dependent upon the adoption of a comprehensive national health system. The same type of coverage could be built into existing private insurance programs. This process could be considerably expedited if federal, state, and local governments would undertake responsibility for stimulating the inclusion of such coverage in private insurance.
Service Delivery and Personnel Training
The achievement of such a financing concept would remove the economic deterrent to medical care related to childbearing. Removal of the economic barriers would go a long way toward making services available. However, experience in other health financing programs has demonstrated that it would not, by itself, remedy the present inequities in the distribution of medical services. It would not create physicians in communities which currently have none or too few, nor build adequate health facilities to replace obsolete ones. It would not guarantee the availability of the necessary trained manpower, nor provide the means whereby individuals would receive the full range of information necessary for them to choose wisely the services which best fit their needs.
These problems can only be remedied if, at the same time that the basic costs are assured through comprehensive health financing mechanisms, systematic attention is paid to the organization and delivery of fertility-related health services. The development of health maintenance organizations and group practice modes of delivery may help in this process. The Commission believes that special attention will have to be directed to the specific problems of fertility-related health services.
We therefore recommend creation of programs to (1) train doctors, nurses, and paraprofessionals, including indigenous personnel, in the provision of all fertility-related health services; (2) develop new patterns for the utilization of professional and paraprofessional personnel; and (3) evaluate improved methods of organizing the delivery of these services.
Family Planning Services
At the same time, federal leadership is necessary to insure that our comprehensive health planning program undertakes responsibility for monitoring the extent to which health services related to fertility are actually provided through our health system, and to initiate changes in practices and programs which are needed to insure that services are actually available and accessible to all.
Until the time that private and public health mechanisms have been altered to include adequate coverage and provision of fertility-related services, the present federal programs that provide family planning services and maternal and child care must be continued and expanded.
The five-year plan for family planning services projects the total fiscal requirements over the next five years at between $392 and $434 million. While state and local governments and private philanthropy can and should increase their commitment to this national effort, most experts agree that by 1975, not more than $50 million can be supplied from these sources.30 The bulk of family planning funds must come from the federal government.
Present specific statutory authorizations for family planning services are not sufficient to meet the level of funding required. Medicaid cannot be expected to provide much assistance.
The Commission therefore recommends: (1) new legislation extending the current family planning project grant program for five years beyond fiscal year 1973 and providing additional authorizations to reach a federal funding level of $225 million in fiscal year 1973, $275 million in fiscal year 1974, $325 million in fiscal year 1975, and $400 million thereafter; (2) extension of the family planning project grant authority of Title V of the Social Security Act beyond 1972, and maintenance of the level of funding at approximately $30 million annually; and (3) maintenance of the Title II OEO program at current levels of authorization.
The program elements thus far recommended would create both a long-term basic financing mechanism for fertility-related health services and an interim program effort to build the needed additional capacity to provide family planning services. To complete the system of fertility-related services, it is necessary to have an adequate information and education program; it is not sufficient just to have services available. People must know that they are available and must have a full range of knowledge about methods of fertility control. The task of informing and educating Americans in this area is too important to be left exclusively to voluntary organizations and sporadic private efforts. It should be the responsibility of society’s full range of information and education channels.
Services for Teenagers
As a society, we have been reluctant to acknowledge that there is a considerable amount of sexual activity among unmarried young people. The national study which disclosed that 27 percent of unmarried girls 15 to 19 years old had had sexual relations, further revealed that girls have a considerable acquaintance with contraceptive methods; over 95 percent of all girls 15 to 19, for example, know about the pill. Contraceptive practice, however, contrasts sharply with this picture. Although many young women who have had intercourse have used a contraceptive at some time, this age group is characterized by a great deal of “chance taking.” The majority of these young women have either never used or, at best, have sometimes used birth control methods. 31
We deplore the various consequences of teenage pregnancy, including the recent report from New York that teenagers account for about one-quarter of the abortions performed under their new statute during its first year.32 Adolescent pregnancy offers a generally bleak picture of serious physical, psychological, and social implications for the teenager and the child. Once a teenager becomes pregnant, her chances of enjoying a rewarding, satisfying life are diminished. Pregnancy is the number one cause for school drop-out among females in the United States. The psychological effects of adolescent pregnancy are indicated by a recent study that estimated that teenage mothers have a suicide attempt rate 10 times that of the general population.
The Commission is not addressing the moral questions involved in teenage sexual behavior. However, we are concerned with the complex issue of teenage pregnancy. Therefore, the Commission believes that young people must be given access to contraceptive information and services.
Toward the goal of reducing unwanted pregnancies and childbearing among the young, the Commission recommends that birth control information and services be made available to teenagers in appropriate facilities sensitive to their needs and concerns.
The Commission recognizes that the availability of contraceptive services alone is insufficient. It has recently been reported that among teenagers, the single most important reason given for not using contraceptives was the belief that, for various reasons, they could not become pregnant. Our survey reveals that nearly two-thirds of our citizens are in favor of high schools offering information on ways to avoid pregnancy. 34
Young people whose family-building years lie in the future and whose options will depend on their understanding of fertility control and services available to them, must have accurate information about these matters.
The Commission therefore recommends the development and implementation of an adequately financed program to develop appropriate family planning materials, to conduct training courses for teachers and school administrators, and to assist states and local communities in integrating information about family planning into school courses such as hygiene and sex education.