December 28, 2005
Population Puzzler: Unwanted Pregnancies and Abortion Trends
Last week, the National Center for Health Statistics issued the results of a survey revealing that the share of American births that resulted from unwanted pregnancies increased from 9 percent in 1995 to 14 percent in 2002. (Seattle Times reports here.)
That’s bad news. It’s also puzzling.
It’s bad news because babies conceived by accident, when mothers do not want to have a child (or another child), tend to have what social scientists call “adverse outcomes,” as discussed here. They’re more likely to have bad prenatal care, die in infancy, fare poorly in school, and suffer violence at the hands of their caregivers.
It’s puzzling because so many reproductive trends have improved since 1995. Pregnancy rates overall have fallen, as shown in this chart for Oregon . . .
. . . especially among teens, as shown in these charts for Oregon . . .
. . . and Washington.
Birth rates overall have fallen. Access to emergency contraceptives has expanded dramatically, as has insurance coverage for prescription contraceptives.
All of these positive trends would make you expect that the share of births that result from unwanted pregnancies has also declined. But the opposite has happened, at least in the United States overall.
The trend is less contradictory within Cascadia. Washington has the best data on unwanted births over time, and they show hardly any change—or hardly any change that’s greater than the margin of error. At best, there's been a tiny decrease in unwanted births.
Still, you’d expect that drops in pregnancies and births would lead to equally dramatic declines in unwanted pregnancies. You’d think, in fact, that improving pregnancy prevention would show itself first and foremost in a declining share of pregnancies that are unwanted. Instead, everything is shrinking dramatically except the “unwanted” percentage!
What’s going on here?
I don’t know.
The Alan Guttmacher Institute (AGI) in New York is reportedly in the midst of an analysis of this puzzler, and I hope they’ll figure it out. In the meantime, let me underline my ignorance by explaining why the obvious answers are probably wrong or, at least, inadequate.
Pro-choice advocates argue that the survey results are a sure sign of deteriorating access to abortion services, which is plausible. In Idaho, Oregon, and Washington, the number of abortion providers is lower now than it was two decades ago. In 1981, there were more than 160 abortion providers in these states; by 2001, there were fewer than 100, according to AGI.
And the next chart, comparing the share of pregnancies ending in
abortion (excluding miscarriages) in British Columbia and
Washington, lends further plausibility to the theory. In British Columbia,
where abortion providers have not decreased in number to the same
degree, abortion has grown as a share of all pregnancies. In Washington, it's shrunk.
Harassment and intimidation from extremists explains some of the drop in abortion providers, but economic consolidation has also contributed. Abortion services have become a specialized medical subdiscipline, concentrated in the hands of fewer providers who are, in general, very good at what they do. First-trimester surgical abortion, therefore, may now be safer and less expensive, in inflation-adjusted terms, than ever before. Convenient, nearby access to safe abortion services does not extend to small-town residents in the inland parts of Cascadia, but most women who want an abortion can get one, by traveling to a city--the same place they have to go for many other surgical procedures.
Anti-abortion advocates have a different exlanation for the rise in unwanted births. They suggest that Americans are demonstrating, in the words of an official at the U.S. Conference of Catholic Bishops, a “pro-life shift.” American women may be exercising their freedom to choose by electing to have fewer abortions. This explanation also has some plausibility. Abortion rates are lower in more-conservative states such as Idaho than in more-liberal states such as Oregon and Washington. Maybe a cultural change is making the whole country more like Idaho. (And maybe the Washington-BC divergence in the chart above is explained not by changing access to abortion but by changing social values.)
Maybe, but I'm dubious. For one thing, British Columbia has the same anti-abortion movements, the same media influences, and the same medical technology (such as ultrasounds that make fetuses seem like babies sooner) as Washington. But abortion trends have diverged.
For another, if the United States were experiencing such a shift, the recent survey should have found not only that “unwanted” pregnancies but also that “mistimed” pregnancies were being carried to term more often. In fact, if a “pro-life shift” were the cause, one would expect a more dramatic increase in the share of births that resulted from merely mistimed (or “too soon”) pregnancies, rather than from pregnancies that were truly never wanted at all. Women who found themselves pregnant a few years before they intended to be (and were swayed by anti-abortion arguments) would almost certainly be the first to forgo abortions, not the smaller number of women who found themselves pregnant despite their wish never to have a child (again). Wouldn’t the easy cases by “shifted” before the hard ones?
The Center found no such shift.
Between the Center’s 1995 survey (careful, enormous pdf) and its 2002 survey (careful, even larger pdf), in subset after subset of American women (young, old, married, cohabiting, Hispanic, white, first-time mothers, third-time mothers, etc.), there’s a marked increased in the share of births that women report as having resulted from unwanted pregnancies. There’s no comparable change for births that result from the far-more-numerous mistimed pregnancies.
(Oh--and just to muddy the waters futher--the same reasoning also counters the suggestion that a paucity of abortion providers explains the rise in unwanted births. If barriers to getting abortions were the problem, it would presumably afflict the more-ambivalent mothers of "mistimed" births even more than it afflicted women with unwanted pregnancies.)
This unwanted-mistimed patter is so unusual that I wonder, did some wording change in the survey skew the response? (The survey report claims the wording was identical.) Did 9/11/2001 shift women’s attitude retroactively, making them less sanguine about childbearing, and less positive about their births? (Seems unlikely, given that the survey was taken many months later and that it covered a five year period.) Did the Center’s statisticians just make a mistake?
And even if there is some statistical fluke explaining this national survey, why isn’t the Washington state “unwanted” number (and it’s similarly static “mistimed” number) dropping with the pregnancy rate?
My own partly formed suspicion centers on the fewer than 10 percent of sexually active women (and their partners) who do not regularly use contraception and therefore account for about half of all mistimed and unwanted pregnancies. If everyone but them is getting better at prevention, their pregnancies may loom larger in national and state statistics. (There are flaws with this theory, too, but it’s the best I’ve got at the moment.)
Anyone else care to theorize?
December 12, 2005
Young at Heart
I'm not sure what to make of this, but it's interesting anyway: Young and Restless in a Knowledge Economy (pdf document), a report on how different urban areas around the US have fared in attracting new residents who are young and well educated.
Now, the report's author clearly believes that attracting talented and entrepeneurial 25-to-34 year olds is a key determinant of a city's economic vitality--a perspective that I'm not entirely sure that I share. (I think, for example, about this Brookings report that shows that cities can have little population growth but plenty of economic growth, as measured by income per capita.)
Be that as it may, the report has a couple of very interesting nuggets about Seattle and Portland. First, central Seattle (or, really, Seattle within a 3 mile radius of the central business district) saw the fastest population growth rate for young adults of any major city the authors looked at. Between 1990 and 2000 the number of residents between the ages of 25 and 34 in and around downtown Seattle grew by more than a quarter. This is especially striking since this group includes the "baby bust" generation born during the low-fertility years of the early 1970s; nationally, the absolute number of people in that age range fell over the decade, as the baby boomers aged and were replaced by the baby busters. (For example, outside of a 3 mile radius from downtown Seattle, the late-20's to early-30's population in the greater Seattle area fell by 5 percent.) So the bigger demographic trends make the concentration of young people in Seattle all the more remarkable.
This trend -- Seattle attracting lots of young adults -- shows itself in other ways as well. In 1990, 25-to-34 year olds were slightly more likely than the average Seattle resident to choose a home close to downtown. But by 2000, they were much, much more likely to choose a home near the city center. Among the cities the report considers, only in Chicago do young people show a greater predilection for living in or near downtown.
Now for Portland. The city ranked third, behind Seattle and Denver, in attracting young adults to the urban core; the population of 25-to-34 year olds in the neighbhorhoods surrounding the city center grew by a little over 20 percent. But Portland's suburbs also did surprisingly well in attracting young people. In fact, metropolitan Portland ranked 3rd among all cities in its "relative attractiveness" to young adults -- the 25-to-34 demographic grew 9 percent faster than the population overall, despite the fact that nationwide the absolute numbers of people in that age group fell.
Much has been made about how few kids there are in Northwest cities. (A year ago, the "fact" that there are more dogs than kids in Seattle made the rounds -- with some interesting discussion in David Sucher's City Comforts blog.) And there's more than a grain of truth here -- there really aren't a lot of kids in the city limits of Portland and Seattle, relative to the to total size of the population. This report may give some clues about why that's so. Well educated women tend to have children later in life; and many of the new young adults in Portland and Seattle have completed 4 year college degrees. So even though Seattle and Portland have attracted lots of people in their peak childbearing years, they seem to have been particularly attractive to precisely the kinds of people who delay childbearing, or who choose to have smaller families.
Which leads to an apparent irony -- the very same trend that some folks are treating as a harbinger of economic growth is causing others to wring their hands over the "childlessness" of the cities. But for my part, I'm not sure that these trends are worth celebrating or condemning. They just are.
November 17, 2005
Plan D for Plan B
The bill is dubbed "Plan B for Plan B."
November 15, 2005
Plan B: Ignore Science, Destroy Evidence
The Government Accountability Office, a nonpartisan investigatory arm of Congress, has released its report on how FDA has handled Barr Pharmaceuticals' application to sell Plan B over the counter.
The findings are damning. Among them:
- Well before FDA scientists had evaluated Plan B, according to GAO, four senior FDA officials were told by their superiors that Plan B would be rejected.
- Top FDA officials intervened in agency decisionmaking, overriding the recommendations of expert review panels and agency scientists, in ways that were "very, very rare."
- The rationale given for overruling those scientists was "unprecedented."
- All of former agency administrator Dr. Mark B. McClellan's emails and other correspondence about Plan B were destroyed, in apparent violation of federal rules.
GAO is notoriously careful in its wording. So it wouldn't be unreasonable at this point to read into these carefully modulated terms official confirmation of our worst suspicions: the Bush Administration's appointees at the FDA ignored the science and ran roughshod over one the most respected and impartial federal agencies to placate its political base. Then it launched a cover up.
Are we getting close to the territory reserved for special prosecutors?
I make these strong charges without partisan rancor. The intensity of my indignation is fired by the knowledge that ready access to emergency contraception reduces both the abortion rate and the teen birth rate. Every month that passes without over-the-counter emergency contraception means more unwanted pregnancies. Unwanted pregnancies lead overwhelmingly to abortions, which--no matter how strongly you support the right to choose--are no one's idea of a public good. To a lesser degree, they lead to births--births of babies who tend to be poorly cared for and at great risk for all manner of ills. And these unwanted pregnancies all could have been prevented with emergency contraception.
As if that tragic waste weren't enough, there is the horrifying prospect of a thoroughly politicized FDA. Let your imagination extend this precedent from emergency contraception to all manner of other pharmaceuticals and, I suspect, you'll share my deep concern.
September 09, 2005
Docs Take the Gloves Off
(Back from my three month sabbatical, I lament writing a first post that rehashes bad news. But this item simply must be marked again.)
Highpoint: A medical doctor and his coauthors write in the staid New England Journal of Medicine:
"The recent actions of the FDA leadership have made a mockery of the process of evaluating scientific evidence, disillusioned many of the participating scientists both inside and outside the agency, squandered public trust and tarnished the agency's image."
They have also kept the abortion and birth rates higher than they need be.
September 08, 2005
Abstinence Makes the Heart Just As Fond
An interesting piece of research from Case Western Reserve School of Medicine suggests that students who completed an abstinence-only sex education showed an increase in "their HIV/STD knowledge, their personal beliefs about
the importance of abstinence and their intentions to remain abstinent in the
That's a good thing, right? Not so fast. Abstinence-only education changed what students said about abstinence. But it didn't make them any more abstinent -- and worse, it may have encouraged a slight increase in risky sexual activity.
...the program did not affect students' avoidance of risky sexual situations. In fact, female students and students already sexually inexperienced reported a decrease in their intent to use condoms.
The study also found the program did not significantly reduce the likelihood the teenagers would engage in sexual intercourse or to use a condom consistently.
Just another example in which actual results trump good intentions.
August 31, 2005
Plan B: I Quit
The Director of Women's Health at the Food and Drug Administration, Susan Wood, resigned today in protest over the agency's delay on a decision to approve the emergency contraceptive "morning after" pill, sometimes called Plan B, for over-the-counter use. Late Friday afternoon, the FDA stated that they would neither approve or reject an application to allow women over 17 to get Plan B without a prescription, citing "unresolved regulatory issues." In response, Wood cited unwarranted interference in agency decision-making in her choice to leave.
The FDA science staff has overwhelmingly favored approval of improving access to Plan B, but the agency has twice delayed the approval, and stated this time around that a formal and "possibly time-consuming" rule making process would be needed for approval. It seems that in what should be a science-based process, the FDA may be bowing to political pressure from the Bush administration and anti-abortion activists to keep the drug off the market with endless delays.
Seven states have already approved over-the-counter access to Plan B, including Washington, and all Canadian pharmacies now offer emergency contraception without a prescription. As we've written about here, and here, universalizing one-stop access to emergency contraception at pharmacies is one of the best public policy options toward reducing the number of unintended pregnancies—perhaps by as much as half. Children conceived intentionally receive better prenatal care and have lower infant mortality rates. Approving better access to Plan B sounds like a good plan for women's health, it's no wonder that Wood said that her employer's actions were "contrary to my core commitment to improving and advancing women's health."
July 20, 2005
Population Gains & Losses
New official population data released today by Washington's Office of Financial Management. The estimates--and they're just estimates--are for every town, city, and county in Washington and 2005.
Here's a quick look at the top 10 fastest growing cities over the past year...
|City||New residents in 2005|
And the top 10 cities for population loss from 2004 to 2005...
|City||Loss of residents in 2005|
July 14, 2005
Future Passed? Notes From Buckley, Washington
Editor's Note: Dan Staley, a frequent commenter on the Scorecard blog, will contribute an occasional column on land use and quality of life from Buckley, Washington, a small town near Mt. Rainier where Dan serves as planning director. This is his first post.
I bicycle a short 5-8 miles to work in Buckley every day, taking different routes through a beautiful pastoral landscape that is full of little surprises. For the past two weeks, I’ve been taking the same route to work and home, in order to see a small herd of elk hanging out on the north side of the White River. These elk are important indicators of Buckley’s future, and I want to be sure I get to know them--at least a little--as I help set the pattern for Buckley’s growth.
I’m the new planning director for Buckley, located in eastern Pierce County, Washington. Buckley’s current population is about 4500 people, all nestled in between the White River and the northern foothills of Mt. Rainier. Buckley also has the last flat land before you head up into the Cascades--and that is the crux of the future challenges we face, being within commutable distance of Seattle and Tacoma and their high-paying jobs.
The citizens of Buckley--like many in the Northwest--are unequivocal in their wish to maintain their quality of life. Folks moved out here to be under Mt. Rainier and to have open space all around--including space in their yards. However, land speculation is rampant and many here wonder what this means for the future of Buckley, as we expect to grow by about 3500 people-–45 percent--in the next 10-15 years. Eric recently wrote about salmon being a canary in a coal mine, and Buckley may serve that same function for many cities on the rural fringe.
So. How do we maintain such a quality of life in the face of land speculation and impending development, while planning for the goals of the Growth Management Act? Do we approach this challenge like so many other towns in Washington are facing, even though we are unlike many of these towns? Do we adopt New Urbanism, even though it doesn’t have a formal theory (it is more like art and science) and we're an exurb? How much do we affect the real estate market to meet Buckley’s goals?
All planners manipulate markets when they plan--zoning arose because cities have externalities ("nuisances"). I have to justify my intervention in the real estate market to meet GMA guidelines, and in my mind, I’m justifying it by making Buckley resilient--as in how an ecosystem is resilient. I avoid concepts like "resilient" or "sprawl" with my neighbors, however, so I explain how it benefits them as individuals: their kids can buy a house here, there are preferred designs, we are making walkable neighborhoods. I also cannot use "sprawl" or "resilient" with decision-makers, so I explain how it benefits the elected’s constituents: efficient services, maintained or improved quality of life, strong businesses.
Oh, and the elk will still be around, too.
Buckley is like a little ecosystem out here, and I want to keep it that way. Please pass along your thoughts on these issues, especially regarding resilience or how you are making your place work.
July 12, 2005
Three Years After The Morning After
The headline is pretty self-explanatory: 'Morning-after' Pill Doesn't Increase Unsafe Sex. (Well, at least it didn't in Britain, where the study was done.) A pdf of the actual article from the British Medical Journal is here.
Note that Washington State was the first state in the US to allow pharmacists to dispense emergency contraceptives without a doctor's prescription, serving as a model for California, Alaska, New Mexico and Hawaii, as well as for British Columbia. See more here.