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ED 232 083 AUTHOR TITLE INSTITUTION REPORT NO PUB DATE NOTE AVAILABLE FROM PUB TYPE EDRS PRICE DESCRIPTORS DOCUMENT RESUME CG 016 777 Eckard, Eugenia Teenagers Who Use Organized Family Planning Services: United States, 1978. Data on Health Resources Utilization Series 13, No. 57. National Center for Health Statistics (DHHS/PHS), Hyattsville, MD. DHHS-PHS-81-1718 Aug 81 25p.; For related document, see CG 016 /78. Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402. Statistical Data (110) -- Reports Research/Technical (143) MF01/PC01 Plus Postage. *Adolescents; Clinics; *Contraception; Early Parenthood; *Family Planning; *Females; Gynecology; Human Services; Medical Services; Obstetrics; *Pregnancy; Secondary Education; Sexuality; Statistical Data ABSTRACT Adolescent childbearing is a major concern because of the associated negative health, social, and economic consequences. To determine whether teenagers are using organized family services to prevent unwanted pregnancies, the National Reporting System for Family Plann.ing Services began in 1972 to collect information on family planning clinic patients in the United States, Guam, Puerto Rico, and the Virgin Islands. Family planning visits to private physicians were excluded from the survey. Since 1977 the survey has included only those visits made for medical services associated with family planning; visits made for replenishing contraceptive supplies, counseling, pregnancy, or venereal disease tests were excluded. The 1978 survey consisted of a sampling of 1,195 randomly selected sites and a systematic selection of visits based on a proportion of each site's reported annual number of visits, and its geographical location. This report of the 1978 survey provides a descriptive analysis, with tables and graphs, of the teenagers under study. The following areas are presented: social and demographic characteristics; pregnancy history; contraceptive utilization and sources of method; contraceptive method switching; and teenagers compared with older women. The appendices provide technical notes discussing survey methodology, data collection and processing, and the reliability of estimates; definitions of terms used in this report; and a copy of the Clinical Visit Record which was used to collect survey data. (WAS) *********************************************************************** Reproductions supplied by EDRS are the best that can be made from the original document. *********************************************************************** liammom ...marsatall111.11 JEN a Teenagers Who Use Organized Family Planning Services: United States, 1978 Statistics obtained from a national sample of visits to organized family planning ciinics are presented for women under age 20 years. Patients are described in terms of social and demographic characteristics in relation to pregnancy history, contraceptive use before and after the visit, and types of medical services received. A comparison of the pregnancy history and contraceptive use of teenage women with that of women age 20 years and over is also presented. Data on Health Resources Utilization Series 13, No. 57 Ellgenia Eckard Division of Health Care Statistics U.S. DEPARTMENT OF EDUCATION NATIONAL INSTITUTE OF EDUCATION EDUCATIONAL RESOURCES INFORMATION CENTER (ERIC) 1 This document has been reproduced as received from the person or organization originating it. XMinor changes have been made to improve reproduction quality. Points of view or opinions stated in this docu . ment do not necessarily represent official NIE position or policy. 2 DHHS Publication No. (PHS) 81-1718 U.S. Department of Health and Human Services Public Health Service Office of Health Research, Statistics, and Technology National Center for Health Statistics Hyattsville, Md. August 1981 Library of Congress Cataloging in Publication Data Eckard, Euvnia. Teenagers who use organized family planning services, United States, 1978. (Vital and health statistics. Series 13 ; no. 57) ((PHS) 81-1718) 1. Birth control clinicsUnited StatesUtilizationStatistics. 2. Birth controlUnited StatesStatistics. 3. Adolescent girls-- l'Oin lical careUnited StatesStatistics. I. Title. II . Series: Vital and health statistics. Series 13, Data from the national health survey ; no. 57. III. Series: DHEW publication ; no. (PHS) 81-1718. RA407.3 A349 no. 57 362.1.10973s 81-11113 1H0766.5.U51 1362.1 21 AACR2 ror sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402 National Center for Health Statistics DOROTHY P. RICE,Director ROBERT A. ISRAEL,Deputy Director JACOB J. FELDMAN, Ph.D., Associate Director for Analysis and Epidemiology GAIL F. FISHER, Ph.D., Associate Director for the Cooperative Health Statistics System GARRIE J. LOSEE, Associate Director for Data Processing and Services ALVAN 0. ZARATE, Ph.D., Assistant Director for International Statistics E. EARL BRYANT, Associate Director for Interview and Examination Statistics ROBERT C. HUBER, Associate Director for Management MONROE G. SIRKEN, Ph.D., Associate Director for Research and Methodology PETER L. HURLEY, Associate Director for Vital and Health Care Statistics ALICE HAYWOOD, Information Officer Division of Health Care Statistics W. EDWARD BACON, Ph D.,Director JOAN F . VAN NOSTRAND, Deputy Director STEWART C. RICE, Chief, Family Planning Statistics Branch Library of Congress Catalog Card Number 81-11113 4 Contents I ntroduction 1 Background 1 Scope of the survey 1 Source and limitations of data 2 Highlights 3 Social and demographic characteristics 3 Pregnancy history 3 Contraceptive utilization and source of method 4 Method switching 5 Teenagers compared with older women 6 References 10 Appendixes I. Technical notes 12 II. Definitions of terms used in this report 16 Ill. Clinic Visit Record for Family Planning Services 18 List of Text Figures 1. Percent distribution of female family planning patients under age 20 years and age 20 years and over by number of preg- nancies, according to age: United States, 1978 2. Percent distribution of female family planning patients under age 20 years and age 20 years and over by prior contraceptive method, according to age: United States, 1978 3. Percent distribution of female family planning patients under age 20 years and age 20 years and over by contraceptive method adopted or continued, according to age: United States, 1978 4. Percent distribution of female family planning patients under age 20 years and age 20 years and over by number of abor- tions since 1973, according to age: United States, 1978 List of Text Tables 6 7 8 9 A. Number of female family planning patients under age 20 years and percent distribution by selected characteristics, according to race: United States, 1978 3 B. Number of female family planning patients under age 20 years and percent distribution by pregnancy history, according to race: United States, 1978 4 C. Number of female family planning patients under age 20 years and percent distribution by contraceptive history, according to race: United States, 1978 4 D. Number of female family planning patints under age 20 years and percent distribution by contraceptive method adopted or continued and medical services provided, according to race: United States, 1978 5 E. Number of female family planning patients under age 20 years and percent distribution by contraceptive method adopted or continued, according to prior contraceptive method: United States, 1978 5 5 Symbols Data not available Category not applicable Quantity zero 0.0 Quantity more than zero but iess thaii 0.05 Z Quantity more than zero but less than 500 * Figure does not meet standards of reliability or precision # Figure suppressed to comply with confidentiality requirements iv Teenagers Who Use Organized Family Planning Services by Eugenia Eckard, Division of Health Care Statistics Introduction Background According to data from the National Reporting System for Family Planning Services conducted by the Division of Health Care Statistics of the National Center for Health Statistics, 33 percent of the 3.8 million women who visited organized family planning clinics in 1978 were teenagers. The Alan Guttmacher Institute estimates that 4 million females ages 15-19 years in 1975 were sexually active.1 This means that approximately 3 out of 10 sexually active teenagers in the United States used organized family planning services in 1978. Along with an increase in teenage pregnancies in recent years, there is growing interest in teenagers' knowledge and utilization of contraception. Adoles- cent childbearing is a major concern because of the associated negative health, social, and economic consequences. A variety of research evidence indi- cates that adolescent childbearing is associqed with higher risks of ill health and social disadvantage for both mother and child. Accordingly, it becomes increasingly important to determine whether teen- agers are using services designed to prevent unwanted pregnancies. There is a paucity of information about adolescents' knowledge, attitudes, and behavior with regard to family planning methods. The limited data available do indicate a trend toward increased contraceptive use by teenagers,2,3 as well as increased use of sources from which medical methods of contraception (i.e., the oral contraceptive pill, intra- uterine devices, and the diaphragm) ate obtained.4.5 The data presented here reveal that teenagers are using the services provided by organized family planning clinics, and, for most of them, this means being introduced to more effective methods of contraception. 7 Scope of the survey The National Reporting System for Family Plan- ning Services was begun in 1972 to collect informa- tion on family planning clinic patients in the United States, Guam, Puerto Rico, and the Virgin Islands. The sources of organized family planning clinics consist of hospitals, health departments, Planned Parenthood affiliates, and other agencies, including community action programs, neighborhood health centers, and freestanding clinics. Family planning visits to private physicians' offices are excluded from the survey. Since mid-1977 the survey has included only those visits made specifically for medical services associated with family planning. Visits for replenish- ing contraceptive supplies, counseling, and pregnancy or venereal disease tests are excluded. The survey employs a two-stage sampling design. Of a universe of 5,619 known family planning service sites, 1,195 were randomly selected as sample sites. This represents about 1 in 4 sites nationally. Survey participation is required for all facilities selected for the sample that are supported by Public Health Service grants for family planning services; how- ever, puticipation is voluntary for nonfederally funded service sites selected for the sample. The proportion of the sample site's visits systemati- cally selected for inclusion in the survey varies according to the site's reported annual number of visits and its geographic location; this averages to about 1 in 25 visits nationally. Other data sources from the National Center for Health Statistics provide related statistics on utiliza- tion of family planning services. For example, data from the National Ambulatory Medical Care Survey, which is also conducted by the Division of Health Care Statistics, concern visits to office-based physi- cians' practices that include family planning services. The National Survey of Family Growth, conducted by the Division of Vital Statistics in 1973 and 1976, provides more detailed statistics on women who made family planning visits to their physicians or to organized family planning clinics in the 3 years prior to the survey. Unlike the other two surveys, data for the National Survey of Family Growth were collected by means of personal interviews with a national sample ot women age 15-44 years who were ever married or never married and who had offspring living in the household. Source and limitations of data The data in this report are based on information obtained from observation, from the medical record, or from the patient interview. This information is entered onto the Clinic Visit Record, or, in those service sites that collected survey data through participation in a computerized record system, on locally developed forms that contain the same 14 items as on the Clinic Visit Record. The items cover basic sociodemographic information about the 2 patient and other information pertaining to family planning (see appendix III for facsimile). Because the 1978 National Reporting System for Family Planning Services was based on a sample, the data differ somewhat from data that would have been obtained had it been based on a full count survey, using the same data collection procedures, materials, and the like. Therefore, estimates of small magni- tudes, as well as percentage estimates based on small numbers, may lack the precision needed for some applications (see appendix I). It should be emphasized that this report focuses on the number of teenagers who used organized family planning services, while another report6 dis- cusses the number of visits made by teenagers to family planning service sites. Both reports use data from the 1978 National Reporting System for Family Planning Services. The following is a descriptive analysis of the teenagers under study and includes a look at impor- tant sociodemographic characteristics in addition to the types of services the teenagers received. Highlights Social and demographic characteristics Table A. Number of female family planning patients under af. 20 years and Percent distribution by selected characteristics, ac- Table A presents data on selected characteristics cording to race: United States, 1978 of teenage family planning patients according to race. Most of the patients, both black and white, were Race 17-19 years of age. However, over twice as many Selected characteristics Total' White smck black teenagers as white teenagers were under 16 years of age (16.3 percent and 7.9 percent, respec- tively). As might be expected, most of the teenagers had not yet completed high school, and the majority (55.7 percent) were students at the time of their clinic visit. Most of the patients were from families who did not receive public assistance. However, the racial difference is striking: A larger proportion of black teenagers were from families who received public assistance (29.8 percent) than was true for white teenagers (7.9 percent). A look at the four geographic regions shows that most of the teenagers were served in the South (36.3 percent). The proportion of teenagers who visited a family planning clinic in the West (27.8 percent) was larger than that for the Northeast (19.9 percent) and North Central (16.0 percent) regions. This differs somewhat when looking at the racial groups sepa- rately. The largest proportion of white teenagers received family planning services in the West (34.5 percent), while more than half of the black teenagers received family planning services in the South (62.1 percent). Table A also reveals that most of the teenagers who visited the clinics were new patients (54.5 percent). This is also true for white teenagers, while the reverse is evident for black teenagers. Pregnancy history Table B shows the percent distribution of teen- agers by number of pregnancies, live births, and fetal deaths. More than half of the teenagers had never been pregnant, while more than three-quarters of them had never had a live birth. More black teenagers than white teenagers had experienced at least one 9 All patients Number in thousands 1,268 892 355 Percent distribution Total 100.0 100.0 100.0 Age 13 years or under 1.0 '0.5 02.2 14 years 2.5 1.7 4.7 15 years 6.8 5.7 9.4 16 years 14.0 13.6 15.1 17 years 21.5 22.1 20.2 18 years 27.1 28.4 23.7 19 yews 27.1 28.0 24.7 Eduction Less than 7 years 1.2 1.0 01.7 7.11 years 60.0 57.2 87.8 12 years 30.8 32.7 25.6 13 yer.s or more 8.0 9.0 5.1 Student status Student 55.7 53.8 60.8 Nonstudsnt 44.3 46.2 39.7 Public assistance income income includes public assistance 14.1 7.9 29.8 Income does not include public assistance 85.9 92.1 70.2 Geographic region Northeast 19.9 21.0 18.0 North Central 16.0 18.1 11.4 South 36.3 26.4 62.1 West 27.8 34.5 8.4 Visit strtus initial 54.5 57.7 45.9 Return 45.5 42.3 54.1 1 Includes rases other tioan white and block. NOTE: Numbers may not add to totals due to rounding. 3 Table B. Number of female family planning patients under age 20 years and percent distribution by pregnancy history, according to race: United States, 1978 Pregnancy history Race Total1 White Black Number in thousands All patients 1,268 892 355 Percent distribution Total 100.0 100.0 100.0 Number of pregnancies None 65.8 69.9 54.6 One 26.3 23.3 33.5 Twoormors 8.1 6.7 11.5 Number of live births None 78.5 83.4 65.3 One 18.0 13.9 28.7 Two or more 3.5 2.7 5.9 Number of fetal deaths None 84.9 84.7 85.1 One 13.3 13.4 13.2 Two or more 2.0 1.9 *0.2 1Includes races other than white and black. NOTE: Numbers may not add to totals due to rounding. pregnancy, and over twice as many black teenagers than white teenagers had had at least one live birth. Since cause of fetal mortality is not ascertained within the scope of the survey, data on the number of fetal deaths may reflect induced as well as sponta- neous abortions. About 15 percent of the teenagers had experienced at least one fetal death. There is no difference in the number of fetal deaths between the two racial groups. Contraceptive utilization and source of method Table C shows the percent distribution of teen- agers by the contraceptive method they were using prior to their visit and the source from which the method was obtained. About 40 percent of the teenagers had never used a method regularly prior to the visit. The proportion who had never used a method regularly was similar for black and white teenagers (39.4 percent and 40.0 percent, respec- tively). For those who had ever used a method, the largest proportion, 48.8 percent, had used the oral contraceptive pill. A smaller proportion of the teen- agers used other methods, which include the intra- uterine device (IUD), diaphragm, foam/jelly/cream, and natural (e.g., rhythm), among others. Such a high proportion of teenagers having used the pill indicates that the source of the method for most of the teenagers was either family planning clinics or private physicians, as table C indicates. The largest proportion of the teenagers returned to the family planning clinic from which they had 4 Table C. Number of female family planning patients under age 20 years and percent distribution by contraceptive hktory, according to race: United States, 1978 Contraceptive history Race Total1 WNW Bleck All patients Number in thousands 1,268 892 355 Percent distribution Total 100.0 100.0 100.0 Prior contraceptive method Pill 48.8 47.13 51.5 IUD 2.3 LB 3.4 D iaphragm 1.3 1.13 0.8 Foam/jolly/cream 2.4 2.13 *2.0 Natural 0.5 "03 *0.3 Steril ization *0.3 0.3 *0.3 Other 4.3 5.3 *1.7 No regular method 39.9 40.0 39.4 Source of prior method Same service site 29.7 26.9 37.2 Other se,rvica site 6.1 6,3 5.9 Hospital 1.1 0.13 *2.0 Pr ivate physician 8.4 9.4 5.6 Drug store 4.1 5.2 '1.4 Other 2.8 3.1) 2.2 Unknown 7.9 8.45 5.9 1Includes races other than white and black. NOTE: Numbers may not add to totals due to rounding. received their prior method (29.7 percent). About 7 percent received their prior method from another clinic or from a hospital. The private physician was the source of prior method for 8.4 percent of the teenagers. The drug store was the source for an additional 4 percent, while 2.8 percent received prior methods from other sources. The source of prior method for another 7.9 percent of the teenagers was unknown. As for racial differences, more black teenagers than white teenagers obtained their prior method from a family planning clinic or from a hospital, while more white teenagers than black teenagers obtained their prior method from a private physician. Table D shows the percent distribution of teen- agers by the contraceptive method they adopted or continued at the visit and the types of medical services they received. Nearly three-quarters of the teenagers chose or continued use of the pill. An additional 8 percent chose either the IUD or the diaphragm, which are other medical methods. There was a small increase in the proportion of teenagers who chose to use foam/jelly/cream after the visit, compared with before the visit (5.0 percent compared with 2.4 percent as shown in tables C and D). Almost 9 percent of the teenagers chose no method at the visit. This general pattern can be seen for both races separately. o It is also evident from table D that more than half of the teenagers received the core medical services provided in family planning clinics, that is, pap smear, pelvic exam, breast exam, blood pressure, and blood test. The pregnancy test was provided for about 10 Table D. Number of female family planning patients under age 20 years and percent distribution by contraceptive method adopted or continued and medical services provided, according to race: United States, 1978 Contraceptive method adopted or continued and medical services isceivad Race Totall White Black All patients Number in thousands 1,268 892 355 Percent distribution Total 100.0 100.0 100.0 Contraceptive method adopted or continued Pill 74.7 74.3 75.8 IUD 3.7 3.2 5.1 Diaphragm 4.2 4.9 *2.0 Foarn/jelly/cream 5.0 4.5 6.5 Natural *0.2 0.2 0.3 Relying on partner 2.8 3.0 2.5 Sterilization 0.2 0.2 *0.3 Other 0.5 *0.6 *0.3 No regular method 8.7 9.1 7.3 Medical services provided Pap smear 62.8 63.7 61.4 Pelvic exam 72.4 72.6 72.1 Breast exam 64.4 64.0 65.9 Blood pressure 89.8 89.0 92.4 Pregnancy test 10.1 10.9 8.2 V.D. test 57.5 57.1 59.4 Urinalysis 62.5 64.3 58.0 Blood test 57.1 57.6 56.6 Other 48.0 47.6 47.9 1Total includes races other than white and black. NOTE: Numbers may not add to totals due to rounding. percent of the teenagers, while nearly 58 percent received the venereal disease (V.D.) testa A majority of the patients also received a urinalysis (nearly 63 percent), and other medical services were provided for 48.0 percent of the teenagers. There is no significant difference in the types of medical services provided to black and white teenagers. Method switching In table E the percent distribution of teenage patients is shown by the contraceptive method they adopted or continued at the end of the visit, according to the method they had used prior to the visit. Before the visit, 2 out of 5 patients used no method regularly (see table C). During the visit, nearly 70 percent of that group chose the pill, over 6 percent adopted the diaphragm or IUD, about 12 percent chose less effective methods, and the remain- ing 12 percent did not adopt a method. Table E also shows that most of the teenagers whose prior method was the pill did not switch to another method (83.9 percent). Almost 5 percent of the teenagers who previously used the pill switched to the IUD or diaphragm, another 5 percent adopted less effective methods, and over 6 percent did not adopt a method at the visit. The general pattern is that teenagers whose previous method was medical (i.e., pill, IUD, or diaphragm) continued that method or chose another medical method. Most teenagers who used less effec- tive methods (i.e., foam/jelly/cream and others) switched to the most effective methods during the *It is important to note that the figures reported here for the veneral disease and pregnancy tests do not include teenagers who visited clinics solely for these services because they were excluded from the survey sample. Table E. Number of female family planning patients under age20 years and percent distribution by contraceptive method adopted or continued, according to prior contraceptive method: United States, 1978 Prior contraceptive method Contraceptive method adopted or continued Pill IUD Diaphragm Foam/ /oily/ Cream Other No regular method Number in thousands All patients 618 29 17 31 67 506 Percent distribution Total 100.0 100.0 100.0 100.0 100.0 100.0 Pill 83.9 *23.6 *29.7 56.7 66.6 69.9 IUD 2.2 59.0 5.2 5.8 *2.3 2.4 Diaphragm 2.5 2.0 51.0 8.5 7.3 4.0 Foamtjally/creem 3.1 5.4 1.6 *17.9 *5.4 6.6 Relying on partner 1.4 2.6 *2.3 2.7 *6.0 4.3 Other 0.5 0.4 *1.4 0.8 2.2 1.0 No regular method 6.3 7.0 8.9 *7.8 9.6 11.7 NOTE: Numbers may not add to totals due to rounding. 11 visit. Thus the clinic provided a method to a significant number of teenagers who had previously used nu method, and it provided a more effective method to teenagers who had previously used a less effective method. Teenagers compared with older women For comparative purposes, figures 1-4 show preg- nancy history and contraceptive information for teenagers and for women age 20 years and over. Figure 1 shows that more teenage patients than older patients had had no pregnancies (approximately 66 percent compared with 31 percent). The proportion who had had one pregnancy was about the same for both age groups. However, more older women than teenagers had had two or more pregnancies (over 43 percent compared with about 8 percent). Figure 2 reveals that a higher proportion of ()leer women than of teenagers used some method of contraception and that more of the former group used the more effective methods. Figure 3 shows that the proportion of teenagers who adopted or continued use of the pill is signifi- cantly larger than that of women age 20 years and over (nearly 75 percent compared with almost 58 percent). Larger proportions of the older women than of the teenagers adopted the IUD and the diaphragm, as well as other methods. However, there is no significant difference in the proportions of teenagers and older women who adopted foam/jelly/cream as a method or who adopted no method. It appears, then, that the pill is the method that is supplied to most women who had never used a method regularly (most of whom are teenagers). Figure 4 reveals the number of abortions the family planning patients had had since 1973. Most of the women, regardless of age, had not had an abortion during that period (nearly 86 percent for teenagers and over 79 percent for older women). However, a higher proportion of the older women than of the teenagers had had at least one abortion since 1973 (over 15 percent compared with nearly 12 percent). The proportion of teenagers who had had at least one abortion since 1973 (almost 12 percent) represents 34 percent of the teenagers who had had at least one pregnancy. 100 90 80 70 65.8 60 50 40 30.8 30 26.3 25.8 20 10 ElUnder age 20 years EIAge 20 years and over None Number of pregnancies One NOTE: Numbers may not add to totals due to rounding. SOURCE: National Reporting System for Family Planning SeMces, 19713NatIonsi Center for Health Statistics. 43.3 8.1 Two or more Figure 1. Percent distribution of female family planning patients under age 20 years and age 20 years and over by number of prognanclee, according to age: United States, 1978 6 100 90 80 70 61.7 6C 50 48.8 40 30 20 12.0 10 2.3 5.5 3.8 1.3 2.4 \, N.1111 Pill IUD Diaphragm Foam/Jelly/Cream ElUnder age 20 years EI Age 20 years and over 5.1 5.4 39.9 11.7 Other Prior contraceptive method NOTE: Numbers may not add to totals due to rounding. SOURCE: National Reporting System for Family Planning Saryices, 1978National Conte. for Health Statistics. No regular method Figure 2. Percent distribution of female With, planning patients under age 20 years and age 20 years and over by prior contraceptive method, according to age: United States, 1978 1 3 7 100 90 80 70 50 50 40 30 20 10 74.7 57.9 3.7 12.1 Pill IUD 9.1 4.2 Diaphragm 5.0 6.0 MI I ID Under age 20 years 1-.1 Age 20 years and over 7.1 3.7 Foam/jelly/cream Contraceptive method adopted or continued Other NOTE: Numbers may not add to totals due to rounding. SOURCE: National Reporting System for Family Planning Services, 1978National Canter for Health Statistics. 8.7 7.9 No regular method Figure 3. Percent distribution of female family planning patients under age 20 years and age 20 years and over by contraceptive method adopted or continued, according to age: United States, 1978 14 8 100 90 85.6 79.4 80 70 60 50 40 30 20 10.7 2.5 1 10 Under age 20 years EiAge 20 years and over None Number of abortions since 1973 One NOTE: Numbers may not add to totals due to rounding. SOURCE: National Reporting System for Family Planning Se Mots, 1978National Center for Health Statistics. 2.8 1.1 Two or more Figure 4. Percent distribution of female family planning patients under age 20 years and age 20 years and over by number of abortions since 1973, according to age: United States, 1978 1 5 References 'Contraceptive Services for Adolescents: United States, Each State & County, 1975. New York: The Alan Guttmacher Institute, 1978. 2Jaffee, F. S., and Dryfoos, J. G.: Fertility control services for adolescents, acceu and utilization. Fam. Plann. Perspect. 8(4): 167-175, 1976. 3Zelnik, M., and Kantner, J. F.: Contraceptive patterns and premarital pregnancy among women aged 15-19 in 1976. Fem. Plann. Perspect. 10(3): 135-142, 1978. 4Dryfoos, J. G., and Heisler, T.: Contraceptive services for adolescents: An overview. Fam. Plann. Perspect. 10(4): 223-233, 1978. 5National Center for Health Statistics: Use of family planning 10 services by currently married women 15-44 years of age, United States, 1973 and 1976, by G. E. Hendershot. Advance Data From Vital and Health Statistics, No. 45. DHHS Pub. No. (PHS) 79-1250. Public Health Service. Hyattsville, Md. Feb. 7, 1979. 6National Center for Health Statistics: Family planning visits by teenagers: National Reporting System for Family Planning Services, United States, 1978, by J. Foster and E. Eckard. Vital and Health Statistics. Series 13-No. 58. DHHS Pub. No. (PHS) 81-1719. Public Health Service. Hyattsville, Md. In preparation. 7Final Report of Data Quality Study for the National Reporting System for Family Planning Services August, 1980, Informatics. (Unpublished). 16 Appendixes Contents I. Technical notes 12 Survey methodology 12 Data collection and processing 13 Reliability of estimates 13 II. Definitions of terms used in this report 18 Ill. Clinic Visit Record for Family Planning Services 18 List of appendix tables I. Estimated number of female family planning patients, by age and race: United States, 1978 14 II. Relative standard error of estimated number of female family planning patients, by age and race: United States, 1978. . . 14 Ill. Number of sample (i.e., unweighted) family planning patient records, by age and race: United States, 1978 14 IV. Range of recommended design effects for proportion estimates 15 1 7 11 Appendix I. Technical notes Survey methodology The National' Reporting System for Family Planning Services covers all family planning visits to nonmilitary service sites in the United States, Guam, Puerto Rico, and the Virgin Islands that offer medical family planning services. The survey specifically excludes family planning visits to office-based private physicians' practices; these visits are included in the National Ambulatory Medical Care Survey, which is also conducted by the Division of Health Care Statistics of the National Center for Health Statistics (NCHS). A family planning patient is an individual making one or more family planning visits to a family planning service site. family planning visits to a family planning service site. Sampling design.The data presented in this report are based on a two-stage stratified sample survey. The first-stage sampling frame was completed during the summer of 1976. The frame consisted of a list of family planning service sites enrolled in the full-count survey (the mode in which the survey operated prior to the adoption of the sampling approach on July 1, 1977) augmented by lists of family planning service sites compiled by the Bureau of Community Health Services of the U.S. Depart- ment of Health and Human Services and by the Alan Guttmacher Institute, which, at that time, was the research and development division of the Planned Parenthood Federation of America, Inc. Family planning service sites that were identified on more than one list were deleted from the frame prior to sample selection. Prior to selection of the sample service sites, the sampling frame was arranged into six State groups, which were formed by combining States with similar numbers of family planning service sites. Within each State group, each family planning service site was classified into one of the following three classes according to reported information for the facility's annual number of family planning visits: sites with 12 less than 1,000 visits, sites with 1,000-3,999 visits, and sites with 4,000 visits or more. Within each of the sampling strata defined by the six State groups and the three visit-size classes, the service sites were ordered by State, type of sponsorship (i.e., public health department, affiliate of the Planned Parent- hood Federation of America, Inc., hospital, and other), and county. The sample service sites were systematically selected from these strata after a random start, with the probability of selection ranging from certainty to 1 in 18. The 197P U.S. sample comprised 1,195 sites, with 85.1 permat of the sites participating in the survey. In the second stage, family planning visits at each sample site were systematically selected. NCHS assigned to each sample site a sampling rate depend- ent on the site's reported visit volume and the State in which the site was located. Overall, 14 visit sampling rates were used to determine the proportion of each site's family planning visits needed for the survey; the visit sampling rates ranged from certainty to 1 in 30. Although the survey is based on a sample of family planning visits, estimates for family planning patients are derivable from survey data. Each patient (i.e., an individual making one or more family planning visits) can be uniquely associated with the first visit she made during the calendar year. The date of the prior family planning visit, if any, for each individual making a sample family planning visit is recorded in item 8 of the Clinic Visit Record (see appendix III). With this information, sample family planning visits that correspond to an individ- ual's first family planning visit during the calendar year can be identified. Of 276,619 sample family planning visits in the United States in 1978, some 138,129 reflect data for the individual's fffst family planning visit during that year. The patient estimates presented in this report are based on those 138,129 sample family planning visitb (or, equivalently, sample family planning patients). Data collection and processing Visit data were either abstracted from the patient's medical file or obtained by interviewing the patient or Sy observation. The primary data collection form is the Clinic Visit Record, which consists of the survey's minimum basic data set (see appendix III). Each sample service site had the option of col- lecting data for the survey by participating in a com- puterized record system, provided NCI-IS criteria for data collection were met. NCHS required that (1) the record system's data be based on a source document that included the survey minimum basic data set, and (2) the procedures and definitions used to collect such data be consistent with those specified for the survey. About 3 out of 4 sample service sites participating in the 1978 survey collected data by participating in a computerized record system. The remaining sites collected survey data on Clinic Visit Records, which were submitted to NCHS for processing. The procedure for sampling visits was done in one of two ways. Sample service sites that collected visit data for the survey by participating in a computerized record system usually opted to have the sample visits selected by computer. The remaining sites selected sample visits through their staffs' maintenance of visit logs used to list every patient making a family planning visit. Individuals who answered "yes" to the screening question ("Are you here to see a health provider [physician, nurse, allied health personnel] about obtaining health services related to contracep- tion, infertility treatment, or sterilization?") were listed consecutively on the visit log. Those individuals whose names appeared on the last line of each page in the visit log were selected and data for those visits were collected. Different versions of the family planning visit logs corresponded to each of the 14 sampling rates employed to select sample visits; the total number of lines used to list patients on the family planning visit log was equal to the reciprocal of the sampling fraction used by the site. Data processing. Data processing differed accord- ing to the mode of data submission. Visit data received on Clinic Visit Records had to be keyed to machine-readable form prior to computer processing. Keying for all data items was independently verified for 100 percent of the Clinic Visit Records. Visit data received on a computer tape or on punched cards from a computerized record system did not require precomputer processing. All visit data, regardless of the form of data submission, were edited by NCHS for completeness and consistency. Visit records with errors, incon- sistencies, or item nonresponse were corrected, if possible, through followup with the service site or the computerized record system. Imputation was used for specific data items when the overall level of nonre- sponse for an item was small. 1 3 Reliability of estimates The survey statistics are derived by a complex estimation procedure used to produce essentially unbiased data. The procedure's two principal com- ponents are inflation by the reciprocal of the proba- bility of sample selection and adjustment for non- response. Sampling error. The statistics presented in this report are based on a sample survey and therefore differ from those that would be based on a full-count (100-percent) surv..y that used the same data collec- tion definitions and procedures. The probability sampling design allows calculation of estimated stand- ard errors from the sample data. The standard error is primarily a measure of the variability that occurs by chance because a sample rather than the entire sampling frame is surveyed. While the standard errors calculated for this report reflect some of the random variation inherent in the measurement process, they do not measure any systematic error, or bias, that is present in the data. One is referred to the section titled "Nonsampling error" for additional information on measurement error.The chances are about 0.68 that the interval specified by the estimate plus or minus one standard error contains the figure that would be obtained through a full-count survey of the sampling frame. The chances are about 0.95 that the interval specified by the estimate plus or minus two standard errors contains the figure that would be obtained through a full-count survey of the sampling frame. In order to derive standard errors at moderate cost that would be applicable to a wide variety of statistics, several approximations were required. It is necessary to utilize the estimates of domain sizes, relative standard errors, and sample sizes shown in tables MII. The standard error of proportion estimates may be approximated by use of the design effect approach. For data from the National Reporting System for Family Planning Services, the design effect varies with the size of the base of the proportion (see table IV). With the selection of larger values in the range of recommended design effects, fewer comparisons of survey parameters will result in significant differences. The largest value in each range of recommended design effects was used to determine reliability for this report. Accordingly, the standard error of an estimated proportion of patients is approximated by the follow- ing formula: JP(' Standard error (p)= (D.E.) P) 13 Table I. Estimated number of female family planning patients, by age and race: United States, 1978 Rice Total AS, Under 20 years 20-24 years 25-29 years 30 years and over Number of patients in thousands All races1 3,815 1,268 1,402 669 475 White 2,818 892 987 441 396 Black 1,118 355 388 210 187 1 includes races other than white end black. Table II. Relative standard error of estimated number of female femily planning patients, by age and race: United States, 1978 Race Total Age Under 20 years 20-24 years 25.29 years 30 years and over Relative standard error in percent All races1 4.1 4.3 4.4 4.5 3.9 White 4.4 4.8 4.7 4.7 3.8 Black 5.2 4.9 4.8 6.6 6.9 1includes races other than white end black. Table Ill. Number of sample (le., unweighted) femily Winning patient records, by age end race: United States, 1978 Race Total Ago Under 20 years 20-24 years 25-29 years 30 years and over All reces1 138,129 48,122 50,922 23,611 15,474 White 99,501 35,463 37,291 16,476 10,271 Bleck 33,872 11,312 11,838 6,155 4,567 1 includes races other than white and black. where lowing computation may be used to determine the standard error for this estimated proportion: p = the estimated proportion. n = the number of sample (i.e., unweighted) patients in the base of the proportion (see table III). D.E. = the design effect corresponding to the size of the estimated base of the proportion p (see table IV). For example, 74.7 percent (p = 0 .7 47) of the 1,268,000 teenage family planning patients continued or adopted use of the oral contraceptive pill. The fol- 14 j (0.747) (1- 0.747) Standard error = 7 48,122 0.014 where p = 0 .7 47 D.E. = 7 n = 48,122 2 Table IV. Range of recommended design effects for proportion estimates Estimated number of patients in base of proportion (domain size) Range of recommended design effects Design effect used in this report to determine reliability Less than 1 million 1-5 1-3 million 1-7 More than 3 million 1-7 and 5 7 0.014 relative standard = = 0.746 0.019. One may also wish to compute the standard error associated with national aggregate estimates. To cal- culate the approximate standard error of an aggregate estimate X , first compute the relative standard error (RSE) of the proportion (X/Y), where Y is the aggre- gate estimate for the smallest category of patients listed in table I containing X population (e.g., if X is the estimated number of teenage family planning pa- tients adopting or continuing use of the oral contra- ceptive pill, Y is the estimated number of teenage family planning patients). Then and RSE(X) = (RSE(X/Y))2 + (RSE(Y))2 standard error (X) = X RSE(X). To continue with the example, one may calculate the standard error of the estimated 946,000 teenage family planning patients who continued or adopted use of the oral contraceptive pill. First, the approximate relative standard error of the proportion estimate (the estimated proportion of teenage family planning patients who continued or adopted use of the pill) is calculated. This was deter- mined to be 0.019. The relative standard error for the base of the proportion (i.e., the estimated total number of teenage family planning patients) is pro- vided in table II. Therefore RSE (946,000) = V(0.019)2 + (0.043)2 = 0.047. The standard error is the aggregate estimate multi- plied by the RSE: Standard error (946,000) = (0.047)(946,000) = 44,462 Nonsampling error. The data presented in this report are also subject to nonsampling error, in- cluding that due to service site nonresponse, item nonresponse, information incompletely or inaccu- rately recorded, and processing error. A major component of nonsampling error is associated with the gap between the survey sampling frame and the universe. The frame only partially covered those sites that had inaugurated the provision of family planning services since early 1976. During early 1980 the National Center for Health Statistics conducted a study to identify and measure nonsampling error associated with 1980 data from the National Reporting System for Family Planning Services .7 The study included site visits to 174 family planning facilities in the 1980 sample. The study revealed that it was not generally possible to verify the number of medical family planning visits. For example, service sites frequently did not differentiate between medical and nonmedical family planning visits. The study indicated patient totals are probably underestimated. Other problems associated with adherence to survey definitions and procedures were identified, and evidence suggests that patient data were not always updated in the site's record system at every visit. Rounding. Aggregate estimates of family plan- ning patients are rounded to the nearest thousand. The percentages were computed based on unrounded estimates; thus, the figures may not add to the totals. 21 NOTE: A list of references follows the text. 15 Appendix II. Definitions of terms used in this report C7inic. See family planning service site. Clinic Visit Record. The primary data collection form used by the National Center for Health Statis- tics for the National Reporting System for Family Planning Services. See appendix III for facsimile. Contraception. Conscious use of medication, de- vices, or practices that permit coitus with reduced likelihood of conception (commonly known as birth control). Contraceptive method. Any medication, device, or practice that permits coitus with reduced likeli- hood of conception. Education. The highest grade of "regular" school completed (not the highest grade entered). "Regular" school refers to any institution in which a person can earn credits toward an accredited elementary school certification, high school diploma, or college degree. Trade schools, beauty schools, business schools, and the like are excluded unless credits are granted toward an elementary school certificate, high school diploma, or college degree. Family planning patient. A person who receives medical services related to contraception, steriliza- tion, or infertility treatment in a family planning sarvice site anywhere within the United States or its territories. Family planning service site. A location provid- ing family planning services on a regular basis under the supervision of a physician. Private physicians' offices and group medical practices are excluded unless they receive a U.S. Department of Health and Human Services grant for the provision of family planning services. Military service sites are also ex- cluded from the survey. Family planning services. Medical services that are primarily related to regulation of conception; that is, they enable a person either to reduce the risk of conception (contraceptive services) or to induce conception (infertility services), as desired. Fetal death. Death of a product of conception prior to complete expulsion or extraction from its 16 mother. This includes miscarriages, stillbirths, and induced abortions. Live birth. A child born alive any time after conception. In the event of a multiple birth, each child is counted as one birth. For example, twins count as two live births, and triplets count as three live births. Medical services. These include the provision of contraceptive methods, general physical examina- tions, and other tests involved in maintaining the health of the patient. The following services are included: Pap smear: Papanicolaou's test to detect cervical cancer. Pelvic exam: Speculum examination of the vagina and bimanual examination of internal pelvic organs. Breast exam: Inspection and palpation of the breast and axillary glands. Blood pressure: Routine measurement of a patient's blood pressure. Pregnancy testing: Any diagnostic test performed to determine pregnahw. V.D. testing: Test to detect the presence of venereal disease. Urinalysis (n.e.s.):b Any test done on the patient's urine sample other than for venereal disease detec- tion or a pregnancy test. Blood test (n.e.s.):b Any test of a patient's blood except for venereal disease detection or a preg- nancy test. Other medical services: Medical family planning services not specified on the Clinic Visit Record. Examples include X-rays and immunizations. New patients. All patients whose first visit (i.e., initial visit) to a family planning service site occurred bn.e.s. means not elsewhere specified. 22 during the survey year. This does not preclude the individual's having visited a private physician. Public assistance income. The patient's family income includes money from any Federal, State, or local public assistance program. Scholarships, educa- tion grants, unemployment benefits, and Social Security pensions are not considered public assistance income. Region. Each of the family planning service sites is classified by location in one of the four geographic regions of the United States, which correspond to those used by the U.S. Bureau of the Census. The following framework is used: Northeast Maine, New Hampshire, Vermont, Massa- chusetts, Rhode Island, Connecticut, New York, New Jersey, and Pennsylvania. North Central. Michigan, Ohio, Illinois, Indiana, Wiscon- sin, Minnisote, Iowa, Missouri, North Dakota, South Dakota, Nebraska, and Kansa. South Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Ken- tucky, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, and Texas. West Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washing- ton, Oregon, California, Hawaii, and Alaska. 23 17 Appendix Ill. Clinic Visit Record for Family Planning Services U S. OEPARTMENT OF HEALTH, EOUCATION, ANO WELFARE PUBLIC HEALTH SERVICE HEALTH RESOURCES AOMINISTRAT1ON NATIONAL CENTER FOR HEALTH STATISTICS Clinic Visit Record for Family Planning Services 1. SERVICE NUMER 2. PATIENT NUMBER 11111111 Number ALN e ASSURANCE OF CDNFIDENTIAUTY-All Informetion which would permit fication of an Individual, a practice, sr an establishment will M held confidential, Mb be owl Only bY Pusan, Maned In and for the Purposes or the survey and will not loo disclosed or released to other persons or und for any other Purpose. Provision of services Is In nil way contingent on the patient's Providing any Information for this form. 111111IIII Number 3. OATE OF THIS VISIT Month Day Year 4. PA7IENT'S SEX 0 Female b D Male 5 ARE YOU OF HISPANIC ORIGIN OR OESCENT2 HAND CARD A a 0 Yes b 0 No 6. PATIENT'S RACE (0114o4 on* box) a 0 White e Asian or Pudic Islander b 0 Black 0 0 American Indlon or Alukan Natio* 11. PREGNANCY HISTORY (Females only) A. Hsu you our bun pregnont? 0 Yes 0 No-. Go to 12 B . How many live births have YOU Me C. Of thus, how rawly are now living? D. How msny of your pregnancies wwe ended by stillbirth, Mixed abortion, or railcards's? (II "zero,"Fo to It I E. How many of these pregnancies were ended by induced abortion since January 11173? F. In what month and year did your lut pregnancy end (regardless of how it ended)? Month Year 7. WHAT IS YOUR BIRTH OATE2 a Date Owl Month b 0 If unknown ask"How old aro you"? OO Day Year (No. of Years) B. PATIENT STATUS Have you ur boon a patient of thh or any other clink for family planning iiial services? 0 vim bONo If "YU," when were you Lula pationt at any clinic for family planning medical services./ --ow month You 9. EOUCATION A. What is the highest grade (or year) of regular school You have completed? (Circle ono numbly) 0 1 2 3 4 5 I 7 8 g 10 11 12 13 14 15 16 17. (If 'Mro,"po to 10) B . Are you prosently a student in a regular school? a 0 Yes 10. FAMILY INCOME ANO FAMILY SIZE HAND CARD Sand HAND CARD C A. Which of the following groups represents your total combined wou (before deductions) family income for the put 12 months? a 0 0111,240 b 0 1111,250.$3,7411 e 0 113,75046,2411 0 SC25048,749 # 0 1118,750+ is 0 118,750413,74g h 0 Unknown f 0 S13,750.8111,749 How rainy people sae in your family, that is, the number supported by this Income? C. Does this income include any public suistancat 0 Yes b 0 No D. What is your relationship to the chief earner? a 0 Chief earner e 0 Daughte/Son to 0 WIre/Husband 0 Othor relative A 3ENCY USE ONLY A c D e F 1. 2. , 3. 4. 5. 12. CONTRACEPTIVE HISTORY A. Have you ever used a mulled of birth control regularly? 0 Yes 0 Ns .Go to 1: HAND CARD D IL What method did you last use malady? (arech oll morn** On 1.0910 0 COMICIT II 0 bbehlAreilY/Cfeelb h 0 Newel (Ineluoling rhythm) I 0 Other 0 Stullization b 0 Oral (PHI) e 0 IUD O 0 Diaphragm 0 Injection C. Do you currently uss that method (printuy method checked In 1211)? 0 vos-4.0o to E b 0 No D. In what month sad year dld you stop using that method? E. How long dld you use that method? _ Days (ir less than a month) Monthll (If less than year) Month VW F. Where wu the method preeerlbed obialudt 0 Thls serviCe lite e 0 Drull (nmpreeeriptien) b 0 Clink (If th*, than t his Mei f 0 Other e 0 Hospital lir ether than this the) g 0 Unknown 0 PrivaU phyliclan 13. MEDICAL SERVICEt PROVIDED AT THIS VISIT 0 Pap smear lo Oiniivcc.itim e 0 Haut exam 0 Mout Pressure 0 Propane?. testing f 0 V.D. testing g 0 Urinalysis (1.84.) h 0 sow test (n.4.4.) 0 Sterlillatien k Infertility treatment m 0 Other Medical Nukes 18 14. CONTRACEPTIVE METHOD AT THE END OF THIS VISIT A. Method Wheat ell Mu *pip/ 0 Sterilization f 0 Cendem Is 0 Orel (pm) g 0 rum/JeliY/Cream e 0 IUD It 0 Natural (Including rhythm) a 0 DIaldwaini I 0 Other 0 Injction k 0 Nene S. If "None," give reason (Check on. ',WI a 0 Pregnant 0 Infertility Patient e 0 Seeking pregnancy HRA-192-I 6/77 Other Medical realms 0 Relying en partner% mistMd f Other 24 Vital and Health Statistics series descriptions SERIES 1. Programs and Collection Procedures.Reports describing the general programs of the National Center for Health Statistics and its offices and divisions and the data col- lection methods used. They also include definitions and other material ne-.:essary for understanding the data. SERIES 2. Data Evaluation and Methods Research.Studie,s of new statistical methodology including experimental tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, objective evaluations of reliability of collected data, and contributions to sta- tistical theory. SERIES 3, Analytical and Epidemiological Studies. -Reports pre- senting analytical or interpretive studies based on vital and health statistics, carrying the analysis further than the expository types of reports in the other series. SERIES 4. Documents and Committee Reports. Final reports of major committees concerned with vital and health sta- tistics and documents such as recommended model vital registration laws and revised birth and death certificates. SERIES 10 Data From the National Health Interview Survey.Statis- tics on illness, accidental injuries, disability, use of hos- pital, medical, dental, and other services, and other health-related topics, all based on data collected in the continuing national household interview survey. SERIES 11 Data From the National Health Examination Survey and the National Health and Nutrition Examination Survey.-- Data from direct examination, testing, Pild measurement of national samples of the civilian noninstitutionalized population provide the basis for (1) estimates of the medically defined prevalence of specific diseases in the United States and the distributions of the population with respect to physical, physiological, and psycho- logical characteristics and (2) analysis of relationships among the various measurements without reference to an explicit finite universe of persons. SE RI ES 12. Data From the Institutionalized Population Surveys.Dis- continued in 1975. Reports from these surveys are in- cluded in Series 13. SERIES 13. Data on Health Resources Utilization.Statistics on the utilization of health manpower and facilities providing long-term care, ambulatory care, hospital care, and family Planning services. SERIES 14. Data on Health Resources: Manpower and Facilities. Statistics on the numbers, geographic distribution, and characteristics of health resources including physicians, dentists, nurses, other health occupations, hospitals, nursing homes, and outpatient facilities. SERIES 15. Data From Special Surveys.Statistics on health and health-related topics collected in special surveys that are not a part of the continuing data systems of the National Center for Health Statistics. SERIES 20. Data on Mortality .Various statistics on mortality other than as included in regular annual or monthly reports. Special analyses by cause of death, age, and other demo- graphic variables; geographic and time series analyses; and statistics on characteristics of deaths not available from the vital records based on sample surveys of those records. SERIES 21. Data on Natality, Marriage, and Divorce.Various sta- tistics on natality, marriage, and divorce other than as included in regular annual or monthly reports. Special analyses by demographic variables; geographic and time series analyses; studies of fertility; and statistics on characteristics of births not available from the vital records based on sample surveys of those records. SE R I ES 22. Data From the National Mortality and Natality Surveys. Discontinued in 1975. Reports from these sample surveys based on vital records are included in Series 20 and 21, respectively. SERIES 23. Data From the National Survey of Famih, Growth. Statistics on fertility, family formation and dissolution, family planning, and related maternal and infant health topics derived from a periodic survey of a nationwide probability sample of ever-married women 15-44 years of age. For a list of titles of reports published in these series, write to: Scientific and Technical Information Branch National Center for Hettlth Statistics Public Health Service Hyattsville, Md. 20782