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Griswold v. Connecticut On June 7, 1965, the U.S. Supreme Court, in Griswold v. Connecticut, struck down state laws that had made the use of birth control by married couples illegal. The court's landmark decision - coming five years after oral contraceptives became available to American women and 49 years after Margaret Sanger opened the first birth control clinic in the U.S. - legalized the use of birth control and paved the way for the nearly unanimous acceptance of contraception that now exists in this country. The court's recognition of individuals' right to privacy in deciding when and whether to have a child in Griswold became the basis for later reproductive rights decisions. In Eisenstadt v. Baird (1972), the court granted unmarried couples access to contraception, and in Roe v. Wade (1973), the court recognized a woman's right to choose abortion. While challenges remain in the struggle to provide universal access to birth control, the court's 1965 decision in Griswold granted constitutional protection to the life-enhancing work of Planned Parenthood and other advocates of reproductive freedom in the U.S. In the 35 years since birth control for married couples was legalized in the U.S., profound and beneficial social changes occurred, in large part because of women's relatively new freedom to control their fertility - maternal and infant health have improved dramatically, the infant death rate has plummeted, and women have been able to fulfill increasingly diverse educational, social, political, and professional aspirations. The ability to plan and space pregnancies has contributed to improved maternal, infant, and family health. In 1965, there were 31.6 maternal deaths per 100,000 live births, many resulting from illegal abortions (NCHS, 1967). In 1996, the rate had been reduced by 76 percent, to 7.6 maternal deaths per 100,000 live births (U.S. Census Bureau, 1999). In 1965, 24.7 infants under one year of age died per 1,000 live births (NCHS, 1967). In 1997, this figure had declined to 7.1 infant deaths per 1,000 live births (U.S. Census Bureau, 1999). Since 1965, there has been a dramatic decline in unwanted births, the result of pregnancies that women wanted neither at the time they were conceived nor at any future time. This decline is particularly welcome because unwanted births are associated with delayed access to prenatal care and increased child abuse and neglect (Piccinino, 1994; Committee on Unintended Pregnancy, 1995). In 1961-1965, 20 percent of births to married women in the U.S. were unwanted. (Mosher, 1988). By 1995, only 6.5 percent of births to married women in the United States were unwanted (Abma et al.,1997).Mistimed births - those that happened sooner than the mother wanted them - have also declined markedly. In 1961-1965, 45 percent of births to married American women were mistimed; (Mosher, 1988); in 1995, only 14.8 percent of births to married women in the U.S. were mistimed (Abma et al., 1997). By enabling women to control their fertility, access to contraception broadens their ability to make other choices about their lives, including those related to education and employment. Since 1965, the number of women in the U.S. labor force more than doubled, and women's income now constitutes a growing proportion of family income. In 1965, 26.2 million women participated in the U.S. labor force; by 1998, the number had risen to 63.7 million (U.S. Census Bureau, 1999). The labor force participation rate of married women nearly doubled between 1960 and 1998 - from 31.9 to 61.2 (U.S. Census Bureau, 1999). In a 1994 survey, more than half of employed women said they provided at least half of their household's income (Lewin, 1995). In 1965 the median family income of married-couple families in which both partners worked was approximately one-half of the median family income of families in which the husband alone worked. By 1997, families in which both partners worked were earning a median income nearly two-thirds higher than the income of families in which the husband alone worked (U.S. Census Bureau, 1998). Among married women who worked full time in 1993, women contributed a median of 41 percent of the family's income (Lewin, 1995). By 1998, 22.7 percent of women in dual-income families earned more than their husbands (U.S. Census Bureau, 1999a). Between 1960 and 1998 the percentage of women who had completed four or more years of college nearly quadrupled - from 5.8 percent to 22.4 percent (U.S. Census Bureau, 1999). Publicly funded contraception programs have increased the ability of lower-income women to exercise the right to control their fertility. Family planning services available through Medicaid and Title X of the U.S. Public Health Service Act help women avoid 1.3 million unintended pregnancies each year. Public funding for contraception helps to prevent abortion - without such funding, the number of abortions in the U.S. would increase by 40 percent. (Dailard, 1999a) The reduction in unwanted births since 1965 is largely a result of Americans' shift to the more effective contraceptive methods that have become available. Among married women using contraception, the percentage using the most effective methods - the Pill, the IUD, tubal sterilization, and vasectomy - grew from 38 percent in 1965 to an estimated 69 percent in 1995 (Mosher, 1988; Piccinino & Mosher, 1998). More than one-third of all women at risk of unintended pregnancy rely on voluntary sterilization - 27.7 percent have had a tubal sterilization and 10.9 percent are protected by their partner's vasectomy (Piccinino & Mosher, 1998). Oral contraception is the most commonly used reversible method - the choice of 26.9 percent of women at risk of unintended pregnancy - followed by the condom, used by 20.4 percent of women at risk of unintended pregnancy (Piccinino & Mosher, 1998). Investing in family planning is cost-effective. One recent study that measured the cost of contraceptive methods compared to the cost of unintended pregnancies when no contraception was used found that the total savings to the health care system falls between $9,000 and $14,000 per woman over five years of contraceptive use (Trussell et al., 1995). The Challenges In the last 35 years it has become clear that making good reproductive decisions does not rest on the legalization of birth control alone - in order to make responsible choices for themselves women and men need access to sexual and reproductive health information and services. Despite the overall reduction in unwanted pregnancy during the last decades, American women still experience some 3 million unintended pregnancies each year - 49 percent of all pregnancies. More than half of unintended pregnancies that do not end in miscarriage or stillbirth are terminated by induced abortion (Henshaw, 1998). Unintended pregnancy is associated with a number of serious public health consequences, including delayed access to prenatal care, increased likelihood of alcohol and tobacco use during pregnancy, low birth weight, and child abuse and neglect (Committee on Unintended Pregnancy, 1995). Cost is a major barrier against access to contraception. Even though birth control is basic to women's health care, many insurance plans do not cover the full range of contraceptive choices, and while funding for contraception for poor women is provided through Title X and Medicaid, funding has not kept up with demand. Though most employment-related insurance policies cover prescription drugs in general, the vast majority do not include equitable cover-age for prescription contraceptive drugs and devices (AGI, 1994). Similarly, while most policies cover outpatient medical services in general, they often exclude outpatient contraceptive services from that coverage (AGI, 1994). From 1980 to 1998, funding for clinics under Title X, the principal federal family planning program, fell by almost two-thirds in constant dollars (Dailard, 1999). Steps to remove economic barriers against access to contraception are succeeding, however, at both the state and federal levels. Since 1998, 11 states have passed legislation requiring health plans to provide coverage for all FDA-approved contraceptives, and health plans for federal employees are now required to cover contraception at an equivalent level to other prescription drugs (PL 106-58). Improved contraceptive use has contributed to the declining U.S. teenage pregnancy rate, though it remains the highest in the developed world. Although the rate of teenage pregnancy in the United States has been declining, it remains the highest in the developed world. Approximately one million American teenagers - about 97 per 1,000 women aged 15-19 - become pregnant each year. The majority of these pregnancies - 78 percent - are unintended (AGI, 1999). Between 1995 and 1996, the national teen pregnancy rate fell 4 percent, from 101.1 to 97.3 pregnancies per 1,000 women aged 15-19 (Henshaw, 1999). This drop contributed to a 17 percent decline since the rate peaked in 1990. Eighty percent of this decline is a result of improved contraceptive use among sexually active teenagers, and another 20 percent is attributable to increased abstinence (Saul, 1999). Studies have confirmed that the results of teenage parenting are often discouraging for both mother and child. Pregnant teenagers are more likely than women who delay childbearing to experience maternal illness, miscarriage, stillbirth, and neonatal death (Luker, 1996). Teen mothers are less likely to graduate from high school and more likely than their peers who delay childbearing to live in poverty and to rely on welfare (Annie E. Casey Foundation, 1998). The children of teenage mothers are often born at low birth weight, experience health and developmental problems, and are frequently poor, abused, and/or neglected (Annie E. Casey Foundation, 1998). Teenage pregnancy poses a substantial financial burden to society, estimated at $7 billion annually in lost tax revenues, public assistance, child health care, foster care, and involvement with the criminal justice system (Annie E. Casey Foundation, 1998). During the last 35 years, women in the U.S. have seen the number of available contraceptive options fall behind those that are available in other countries. The two most popular methods of reversible contraception among married women in 1965 - the Pill and the condom - remain the two most popular reversible methods today (Piccinino & Mosher, 1998; Ryder & Westoff, 1971). Two methods approved in the past decade are Norplant®, a subdermal contraceptive implant that lasts for up to five years, and Depo-Provera®, an injectable contraceptive that lasts for 12 weeks. Yet when Norplant was approved by the FDA in 1990, it had already been in use in many countries for nearly a decade (Boonstra et al., 2000). Depo-Provera, which was approved for use in the U.S. in 1992, had already been used by more than 30 million women in 90 countries for over 30 years (Connell, 1994). Emergency contraception, which can prevent pregnancy after unprotected intercourse, has been available to women for more than 25 years. However, it was not until 1998 that the first dedicated emergency contraceptive pill was approved by the U.S. Food and Drug Administration. Widespread use of emergency contraception could prevent an estimated 1.7 million unintended pregnancies and 800,000 abortions each year (Glasier & Baird, 1998; Van Look & Stewart, 1998). The continuing lack of sufficient options for reversible contraception has led many women to rely on perm-anent methods. Sterilization is the contraceptive choice of more than one-third (39 percent) of all couples. Among women 30-34 years of age, sterilization is also used more than any other method of contraception. Even women 25-29 years of age - 17 percent - rely upon permanent methods (Piccinino & Mosher, 1998). For many women and couples, sterilization is not the ideal method of contraception, but it may be the best option available to them. In fact, a 1988 study funded by the National Institutes of Health showed that 30 percent of the low-income women who intended to be sterilized did not understand that the procedure would make it impossible for them to have more children (Cushman et al., 1988). The development of further options for reversible methods of contraception would offer many people more desirable alternatives to permanent, surgical methods. The Institute of Medicine's Committee on Contraceptive Research and Development recently recommended "that, to make a full range of contraceptive products accessible to consumers and to increase demand for contraceptive products to something closer to the level of unmet need, there should be continued and sufficient government support of contraceptive services. . . . The committee also recommends that third-party payers, who bear the costs and may reap the benefits of the health status of their covered populations, include contraception as a covered service. Ideally, family planning services and the management of sexual health would be integrated as components of comprehensive reproductive health services (Institute of Medicine, 1996)." Women and men no longer need to abstain from sex for fear of having more children than they can afford or in terror of endangering a woman's health with a high-risk pregnancy. In 1965, 35 percent of married women in the U.S. used a safe and effective method of family planning. Only one out of 10 women in the developing world did so. Today more than 50 percent of couples worldwide rely on modern methods of birth control to maintain the health and well-being of their families (Ryder & Westoff, 1971; Robey, 1994). We have come a long way - but we have a lot farther to go. Although great advances in contraceptive technology have been made in the last half of the 20th century, there is pressing need for a much wider range of birth control options. No single method can work for everybody - women and men's economic circumstances, health needs, lifestyles, and personal preferences are highly individual. To fill those individual needs, more safe and effective contraception options are needed. Cited References Abma, Joyce C., et al. (1997). "Fertility, Family Planning, and Women's Health: New Data From the 1995 National Survey of Family Growth." Vital and Health Statistics, 23(19). AGI - Alan Guttmacher Institute. (1994). Uneven and Unequal: Insurance Coverage of Reproductive Health Services. New York: Alan Guttmacher Institute. _____. (1999, accessed 1999, October 5). Facts in Brief: Teen Sex and Pregnancy [Online]. Annie E. Casey Foundation. (1998). When Teens Have Sex: Issues and Trends. Baltimore, MD: Annie E. Casey Foundation. Boonstra, Heather, et al. (2000). "The 'Boom and Bust Phenomenon': The Hopes, Dreams, and Broken Promises of the Contraceptive Revolution." Contraception, 61(January), 9-25. Committee on Unintended Pregnancy. Institute of Medicine, National Academy of Sciences. (1995). The Best Intentions: Unintended Pregnancy and the Well-Being of Chi

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