lag behind whites regardless of poverty status. This would again appear related to the scarcity of physicians in black communities. The importance of the premarital consultation for improving the effectiveness of contraceptive practice is suggested when these findings are related to data on interval of first contraceptive use. As Figure 4 illustrates, there is a consistent relationship between a professional family planning consultation at marriage and initiation of contraception before the first preg. nancy: While there may again be some self-selection at work, in most subgroups the probability of initiating contraception before the first pregnancy is two to three times greater among couples who had a professional consultation at marriage than among those who did not. The change since 1966 is particularly striking and appears to explain, in part, why such a relatively large proportion of recently married couples are currently using the most effective methods. The premarital consultation thus appears to be an important key to initiation of contraception early in the Table 25.-Proportion of Wives Who Discussed Family Planning with Physician at Time of Marriage, by Color, Poverty Status and Marriage Duration 34 26 282 5 11 361 poverty status a 52 148 10 5 158 Total White Nonwhite Below 150% of poverty Total 29 1,722 White 2,656 Nonwhite 240 33 34 333 Above 150% of poverty 10 279 10 339 Total White Nonwhite 43 47 10 aFewer than 20 cases. Source: 1970 National Fertility Study. Source: 1970 National Fertility Study. family formation cycle and its use for child spacing as well as family limitation. It also appears to influence the pattern of contraceptive use throughout the process of family formation. Figure 5 assembles information on the proportion initiating contraception by specified pregnancies for couples who did or did not have a premarital family planning consultation. In each subgroup, couples who did not have a premarital consultation are two or three pregnancies behind those who did in reaching the same proportion initiating contraceptive use. In each subgroup also, the proportion who had never used contraception is two to five times higher among couples who had not discussed family planning with a physician when they were married. For improving the efficiency of contraceptive practice, therefore, the premarital family planning consultation appears to be a critical point for medical intervention. Policies and programs to stimulate more physicians to provide this vital family planning service are discussed in a later section. THE CONTRACEPTIVE REVOLUTION AND THE SHIFT IN PUBLIC POLICY The family planning experience of married couples during the 1960's has been characterized as "a contraceptive revolution,"49 set off by the emergence of the Pill and the intrauterine device, and sustained by a decline in fertility preferences and, perhaps, by an apparent change in sexual attitudes. Significant shifts in the timing and scope of contraceptive practices have been associated with such basic social changes as increased urbanization, higher educational levels, and improved living standards, and by a considerable moderation of the historic religious controversy over permissible means of fertility regulation. They have also been accompanied by a sizable shift in public policy, perhaps both as effect and cause. Before summarizing the policy and program implications of this analysis of the current situation, it seems useful to review briefly the principal changes in public policy during the last decade. Throughout most of American history, public policy-as expressed in laws and the policies of governmental agencies-made it difficult for health professionals to dispense, and for couples to secure, contraception. The Federal Comstock law-adopted in 1873 and only repealed in 1971-and most state laws patterned after it bracketed contraceptives with "obscene or pornographic materials" and restricted dissemination of information about them as well as their sale.50 Court decisions helped to moderate the impact of these laws, and United States fertility studies make clear that, to some extent, they were honored more in the breach than in the observance, attesting to the deeply felt desires of many American couples to limit their fertility. Yet these laws Figure 5. Percent Initiating Contraception By Specified Pregnancies for Couples Who Did or Did Not Discuss Family Planning with Physician at Marriage, By Color and Poverty Status had a chilling effect on public and professional attitudes and on the policies and practices of health institutions and individual physicians. These effects were most apparent in the administrative policies of governmental agencies and institutions. Even for couples who did not depend for their medical care on publicly funded health agencies, however, they stigmatized contraceptive practice and created obstacles to securing medical contraception. While efforts to repeal restrictive laws were pursued in the 1940's and 1950's, the shift in public policy began, paradoxically, with changes in administrative policies. A major turning point occurred in 1957-1958 in New York City with a protracted and successful campaign to reverse the longstanding ban on contraceptive prescription in the city's municipal hospitals,51 a prohi bition which was then customary in most governmentoperated health services. At that time, birth control was offered in maternal health programs of only seven state public health departments and then only in token fashion. Apart from authorizing hospital physicians to prescribe birth control, the New York campaign's major significance was to demonstrate unmistakably the extent of actual public support for family planning. Virtually all major non-Catholic organizations, with considerable support from the relevant professional groups, united to seek reversal of the ban, leaving only several Catholic organizations and a few city officials defending the status quo. The essential elements of the settlement formula-legitimation of birth control as an integral part of regular medical services, coupled with recognition of the importance of voluntarism and respect for varying religious beliefs-served as the prototype for settlement of similar controversies and near-controversies in many other communities.52 The New York change laid the groundwork for the provision of family planning in publicly administered health institutions throughout the country. In 1959, following the report of a Presidential committee urging the incorporation of assistance for population programs into foreign aid for nations requesting it,53 discussion of public policy on family planning became intertwined with discussion of the population problem. The ensuing debate was marked by the opposition of the Catholic Bishops of the United States to the use of public funds for birth control programs at home or abroad,54 and President Eisenhower's statement of opposition to a governmental program55 position which he reversed in 1963),56 (a Beginning in 1961, a series of addresses by high officials of the Kennedy Administration elaborated the government's increasing concern with the impact of rapid population growth. The National Institutes of Health acknowledged responsibility to finance basic research in reproductive physiology which might lead to improved methods of fertility control; this area of investigation was assigned to the newly formed National Institute of Child Health and Human Development (NICHD). In April 1963, the quasi-governmental National Academy of Sciences issued its first report on worldwide dimensions of the population problem, calling for active government participation in efforts to curb uncontrolled population growth;57 and President Kennedy formally endorsed expansion of reproductive research so that knowledge could "be made available to the world so everyone can make his own decision."58 By the end of 1963, Washington attitudes had changed sufficiently to permit Congress to adopt an amendment to the foreign aid bill authorizing use of assistance funds for "research into problems of population growth."59 In its second population report, dealing with United States growth, the National Academy of Sciences urged that family planning be made an integral part of domestic public medical programs, and suggested that the appointment of an official "at a high national level" might facilitate Federal action.60 This was proposed in legislation introduced in 1965 by a distinguished group of Senators and Representatives headed by Senator Ernest Gruening and later implemented, in part, by the appointment of a Deputy Assistant Secretary for Science and Population in the Department of Health, Education and Welfare (HEW). The first major statutory changes came at the state level in 1965 and 1966, when the increasingly rapid legitimation of birth control found expression in a series of legislative actions which must be judged remarkable for the relative lack of controversy which accompanied their enactment. Five states-New York, Ohio, Massachusetts, Minnesota, and Missouri-removed Comstockera restrictions on dissemination of contraceptive information. Bills authorizing or encouraging public health departments and/or welfare boards to provide family planning services at public expense were adopted in California, Colorado, Florida, Georgia, Illinois, Iowa, Kansas, Michigan, Nevada, Oklahoma, Oregon, and West Virginia. And the United States Supreme Court struck down Connecticut's archaic statute-the only one in the country which prohibited use of contraceptives-in a landmark decision establishing the constitutional right of couples to plan their families free of state interference.61 Beginning with his 1965 State of the Union message, President Johnson referred on at least 42 occasions to the problems associated with population growth. HEW's first policy statement was issued in January 1966, and the Department's position was further elaborated by Under Secretary Wilbur Cohen in a major address later that year. 62 The clearest statement of the objectives of United States domestic policy was contained in the President's 1966 Special Message to Congress on Health and Education, in which he singled out family planning as one of four critical health problems requiring special attention, declaring: We have a growing concern to foster the The first concrete Federal actions in family planning were taken by the antipoverty program administered by the Office of Economic Opportunity (OEO). In 1965, medical family planning services were still not being provided by most publicly funded health facilities. OEO began in that year to make specific grants to community action agencies to support family planning service projects for low-income patients. At the same time, comprehensive maternity-care projects funded by HEW, designed primarily to reduce the incidence of mental retardation among children born to high-risk low-income mothers, enabled some health departments to initiate the provision of family planning services. The number of states in which local health departments provided at least referrals for family planning services increased to 40.64 Among state welfare departments, positive policies authorizing referral of assistance recipients to family planning services and, in some cases, reimbursements for such services, were adopted in at least 33 states. While policies were changing rapidly, the actual performance of Federal and state agencies in the family planning field lagged considerably. The Federal role in biomedical research was implicitly acknowledged to be inadequate in 1965 when the NICHD Advisory Council strongly admonished the agency to take the initiative in stimulating increased work on human fertility, sterility, and family planning.65 In regard to family planning services, a review of HEW programs in 1967 found that none of the Department's operating agencies "presently places high priority on family planning or is certain what precise functions it is expected to carry out in this field."66 Uneasiness over the slow pace of the Federal effort led in 1967 to the first specific Congressional actions on domestic family planning. In the 1967 Amendments to the Economic Opportunity Act, Congress voted to designate family planning as a "special emphasis" component of the antipoverty program.67 Congress also amended the Social Security Act to earmark for family planning service projects not less than six percent of funds appropriated for maternal and child health programs administered by HEW, and to require the states to offer and provide family planning services to all appropriate public assistance recipients.68 Funds for family planning programs overseas were also earmarked in the foreign aid legislation.69 During this period, statutes prohibiting abortion except to save the mother's life began to be challenged in a number of states. Beginning with the reform of the Colorado law in 1967, 17 states in the next four years repealed or reformed their laws through legislative action or court decisions. In 1968, President Johnson appointed a Committee on Population and Family Planning to assess the adequacy of the overall Federal program. In its report at the end of the year, the Committee recommended rapid expansion of funding and strengthening of the adminis trative machinery for the three principal components of the Federal program-family planning services at home for persons who need and want them, biomedical and behavioral research to develop improved contraceptive methods and better understanding of population dynamics, and assistance to family planning programs in developing countries.70 Legislation to implement the Committee's recommendations was introduced in both Houses early in 1969. In July, President Nixon sent his Population Message to Congress, calling for increased Federal efforts in services, research, and foreign aid and requesting the establishment of a Population Commission, a bill which was enacted in March 1970.71 The year closed with the adoption in December, by a 298-32 margin in the House and without opposition in the Senate, of the Family Planning Services and Population Research Act. A modified version of the original legislation to implement the recommendations of the President's Committee, the law authorized $382 million for services and research and constituted the first major legislation specifically devoted to family planning and population to be adopted by the Congress.72 To administer the domestic programs, two agencies were created by HEW: the Center for Population Research (CPR), established in 1968 as a unit within the aforementioned National Institute of Child Health and Human Development; and the National Center for Family Planning Services (NCFPS), created in 1969 as an agency within the Health Services and Mental Health Administration (HSMHA). The current administrative structure was completed in 1970 with the creation of the post of Deputy Assistant Secretary for Population Affairs, who was given line authority over the NCFPS and CPR programs (which also report to the directors of HSMHA and NIH). Figure 6 shows, in outline form, the present organization in HEW for family planning and population programs. (The OEO and foreign aid programs are administered by their respective agencies.) The change in United States public policy toward family planning which occurred during the 1960's was thus expressed in numerous legislative and administrative actions at Federal, state, and local levels. The consequences of these changes can be evaluated directly in the increasing Federal commitment for family planning service projects (from less than $1 million dollars in FY 1965 to $106 million in FY 1972) and for population research (from "close to nothing"73 to $38 million in FY 1972). They can be traced in the increased involvement of state and local governmental agencies and in the expansion of service and research projects operated by both public and nonprofit organizations. And they can be measured by the increasing numbers of couples with low or marginal incomes who have begun to utilize modern methods of fertility control. By making the best medical methods more widely available to these couples, the public program appears to have contributed significantly to the narrowing of the differences in contraceptive use between poor and nonpoor observed from 1965 to 1970, and to a decline in fertility rates among poor and near-poor women in the last half of the decade more rapid than among women above the near-poverty level. Less measurable, but no less significant, have been the indirect effects of the policy change. By supporting the development of programs and facilitating public discussion of fertility control and population problems, |