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23. Adolescent Pregnancy Approximately ~ million teenagers become pregnant each year; about half of them give birth. Although the birthrate for teenagers has been declining for many years, adolescent pregnancy, abortion, and childbearing are considerably higher in the United States than in most developed countries." There are serious health and social consequences for both teen mothers and their children. Infants of adolescent mothers under age 15 are twice as likely to have low birth weight, according to Richard Smith of the March of Dimes Birth Defects Foundation.2 (~203) These mothers are more likely to experience toxemia, anemia, and other complications during pregnancy, says the American School Health Associa- tion (AS HA). (~006J For young teen mothers (15 and younger), the risk of maternal death is three times as high as for mothers aged 20 to 24, according to Walter Ostergren of Life Planning/Health Services in Dallas.3 (~640) In addition, Smith, Ostergren, and others report that teenage mothers do not achieve income or educational levels as high as those who become mothers later.4 (~006; #~0) However, the problems associated with adolescent pregnancies and births must be examined in the social and economic climates in which most of these preg- nancies occur. Research has established a strong link between poor socioeconomic status and early, some- times socially accepted, sexual activity. In addition, many witnesses point to the fact that for some teenagers, pregnancy is intentional. Thus, to have an impact on the adolescent pregnancy rate, public health efforts must look beyond the obvious and dramatic statistics to the broader and deeper social issues that weigh heavily on this problem. The 44 witnesses who focused on adolescent pregnancy and reproductive health highlighted efforts in several locales-Texas, Detroit, Rhode Island, Colorado, Los Angeles County, and elsewhere-that are aggressively combating teenage pregnancy and its adverse outcomes. They also identified additional measures that still must be taken or expanded if targets are to be met. The 1990 goals for reductions in teenage fertility will not be met, witnesses say. (~218; #279; #360) Testimony provided evidence that preventive strategies can reduce teenage pregnancy rates and adverse pregnancy outcomes. Smith, for example, 176 Healthy People 2000: Citizens Chart the Course reports that a program sponsored by the March of Dimes Birth Defects Foundation at Henry Ford Hospital In Detroit reduced the neonatal mortality rate among infants of adolescent mothers from 25.6 per 1,000 to 8.4 per 1,000 over a six-year period. (i203) However, Denman Scott, Director of the Rhode Island Department of Health, notes that teenage pregnancy rates are lower in 32 developed countries than they are in the United States, despite the fact that teens begin sexual activity equally as early.5 (#461) Deborah Bastien of Galveston, Texas, adds that in those countries, family planning services and sex education are more widely available.6 (~236) CONTRIBUTING CAUSES Availability and Use of Contraception According to Ostergren, there are about 5 million sexually active teenagers in the United States who need contraceptives, but family planning clinics serve only about half of them.7 (~640) Witnesses note that by the time most teenagers seek contraceptives, they have been sexually active for at least a year. Reasons given for failing to obtain contraceptives include economic barriers and inade- quate education about contraception and pregnancy. (#006; #236) For some Hispanic teenagers, especial- ly those using public clinics, there are additional barriers; often, they are asked questions about their legal status, which discourages them from going to clinics, according to Peggy Smith of Baylor College of Medicine.8 (~308) Another problem is that teen- agers may fear visiting a private physician because of confidentiality concerns. An American College of Obstetricians and Gynecologists (ACOG) spokesper- son pointed out that his organization is working to assure teenagers that they are entitled to guarantees of patient-physician confidentiality, except in extraor- dinary circumstances. (#279J For most teenagers, pregnancy reflects a failure to use contraceptives or contraceptive failure. Yet for some, it represents a conscious decision about how to proceed with their lives. (~003; #308; #640) For example, among adolescent Hispanic teens in Texas, Smith says that from 22 to 63 percent of pregnancies

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are intended. The consequences of out-of-wedlock pregnancy are seen as "negligible," she says.9 (#308J Similarly, in the Black culture in Texas, childbearing is seen as a right of passage into womanhood and the child is often a source of pride to the grandmother. Marriage for Blacks was forbidden during slavery and still is not a social norm. f#797J Unintended preg- nancies are related both to the unavailability of family planning services and to a reluctance on the part of teenagers to obtain or use contraceptives, according to witnesses. However, teenagers do not always con- tinue the use of contraceptives once they have been obtained, according to testimony, and this matter should be targeted in education and outreach efforts. Low-income women are more likely to discontinue contraceptive use than higher-income women, accor- ding to Diana Bonta of the Los Angeles Regional Family Planning Council. (#024) SocioeconomIc Factors The testimony of several witnesses makes clear, however, that the issue of teenage pregnancy often goes beyond contraceptives. What also must be considered is the social environment and the resultant self-image and outlook on life. A number of studies have looked at the relation- ship between socioeconomic status and teenage pregnancy or early sexual activity. Although studies differ in methodologies, populations studied, study objectives, and so on, many point to the fact that chronic economic disadvantage may give rise to out- looks on marriage and family that make early sexual behaviors acceptable. A number of studies also sug- gest a strong association between low intellectual abi- lity, low academic achievement, lack of educational goals, and early sexual experience among both Black and White students. Religiousness, on the other hand, regardless of the faith, appears to lead to initiating sexual activity at a later age.~ Edna Batiste of the Primary Care Network of the Detroit Department of Health describes a syndrome that characterizes many pregnant Black teenagers that she sees. The girl's environment involves poverty, single-parent homes, increasing high school dropout rates (now 40 percent in Detroit), and unemployment. She has a baby, drops out of school, and gets a low- paying job, if she can get a job. She does not want to marry the father because he has no job, is on drugs, does not care, or disappears. Welfare becomes necessary and self-esteem is low. (#016) Other testifiers agree. Mary Lou Balassone of Seattle, Washington, states her belief that just like teen pregnancies, the high rate of repeat pregnancies "is tied to economic and social factors." (#246) When a teen becomes pregnant, education is the first "luxury to be dismissed, followed closely by youthful dreams and aspirations, according to Cathy Trostmann of Houston. (#302) Devising strategies for keeping teens in school is a priority for Jackie Rose of the Clackamas County Department of Human Services in Oregon. As an example, she suggests Teaching teens and their families techniques for success.n (#343) Bernard Turnock of the Illinois Department of Public Health calls for "increased education and job training opportunities to impact the social and economic factors" contributing to a higher rate of pregnancy among non-White adolescents. f#215) PREVENTION STRATEGIES One approach to preventing teenage pregnancy is sex education in the schools. Although this topic has prompted considerable public debate, witnesses did not reflect the polar views sometimes heard. No one argued against sex education in schools. Many wit- nesses, including some who testified specifically about AIDS or sexually transmitted disease, proposed objec- tives aimed at including sex education in the health curriculum beginning in the early grades. The American School Health Association (ASHA) says that mandatory school-based sex education has not been pursued as aggressively as it should because of the controversy surrounding the timing and content of such programs. Yet the ASHA notes that Gallup polls show increasing support for school-based sex education; recent polls indicate that 80 percent now favor it with parental consent. The ASH recom- mends that agencies receiving federal funds for AIDS education be required to expand their programs to include pregnancy prevention. (#006) Conversely, others suggest that information about AIDS and other sexually transmitted diseases also be included in education efforts aimed at preventing adolescent pregnancies. Some witnesses suggest that the benefits of delay- ing sexual activity be stressed in adolescent education programs, but others feel that relying on this message is not sound. Ezra Davidson, representing the Ameri- can College of Obstetricians and Gynecologists (ACOG), comments: "If we adopt an unrealistic and unbelievable line of reasoning that the only acceptable behavior is abstinence, we can probably not expect to see continued progress in reducing unintended teenage Adolescent Pregnancy 177

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pregnancies. (~279J Davidson describes arrange- ments that ACOG has made with the national televi- sion networks to broadcast public service announce- ments. These announcements carry two messages: (I) sex before you can accept responsibility for it is not desirable; and (2) if you have sex, the responsible thing is to protect yourself against unintended preg- nancy. (#279) Several studies have documented the success of school-based clinics- that is, primary health care centers located on school grounds-in helping reduce adolescent pregnancies. The ASHA cites several school-based clinics in St. Paul in which birth rates dropped 40-50 percent, with about 80 percent of those having babies remaining in school. (~021) In another inner-city study, junior and senior high school students received sexuality and contraceptive educa- tion, counseling, and medical and contraceptive services at a clinic several blocks from the school. Among students exposed to the program, pregnancies increased 13 percent after 16 months; among non- program students, the increase was 50 percent. After 28- months, pregnancies declined 30 percent for those in the program and increased 58 percent for non- program students.~3 (~006J Bonta says that although the typical client at the Los Angeles Regional Family Planning Council is be- tween 20 and 34 years of age, the council has several goals designed to enhance life options for adolescents, particularly low-income ones. Its sconces to teens include providing incentives to defer sexual activity, programs to reduce unintended pregnancies, and pro- grams to improve the availability of contraceptives. She identifies several components of the program: upgraded family life planning courses, including male responsibility; programs to improve school perfor- mance and staying in school; afterschool programs; programs to improve family relationships or develop positive adult role models; employment programs; teen peer counseling programs for the 9 to 12 age group; outreach efforts to high school dropouts; and school-based programs to set individual goals, because REFERENCES pregnant teens have lower educational and occupa- tional goals. r#o24' Other witnesses emphasize the importance of addressing the larger social context of adolescent pregnancy. They mention communiW-wide efforts involving employment and other programs to combat the problem. `#006; #016; #215' Batiste says that the classic public health approach, involving teams of professional community health workers who work face to face with teens in selected districts, is needed. These efforts can reach teens who have dropped out of school, as well as those still enrolled. t~0164 George Flores of San Antonio's Metropolitan Health District emphasizes the need to involve schools, churches, and parents in community programs. (#745) Prevention strategies should focus not only on preventing the first pregnancy but also on avoiding repeat pregnancy, says Balassone. For example, in a group of teenagers interviewed in 1979, 17.5 percent of those who had had a premarital pregnancy were pregnant again within a year. Within two years, 31 percent had a repeat pregnancy. t4 (~246) Donnie Hanson and Peter Vennewitz of the Washington State Department of Social and Health Services recommend adding an objective that the number of adolescents experiencing second or subsequent births be no more than 10 percent of those giving birth. (~218) Other strategies identified by witnesses include increased availability of family planning services and contraceptives; increased use of nurse midwives to provide contraceptive information, because they can do it effectively and at a lower cost than physicians (#003~; and enclosing educational material about preventing pregnancy in tampon and sanitary pad boxes, as is done for toxic shock syndrome f#360~. A few witnesses note that recent research suggests a link between sexual abuse and pregnancy among young teenagers, and suggest that increased efforts aimed at preventing sexual abuse of children could affect the pregnancy rate among young teens. `#215; #2183 1. Hayes CD (Ed.): Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing, vol. I. Washington, D.C.: National Academy Press, 1987 2. Friede A, Baldwin W. Rhodes PH, et al.: Young maternal age and infant mortality: The role of low birthweight. Pub Health Rep 102~2~:192-199, 1987 178 Healthy People 2000: Citizens Chart the Course

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3. Hughes D, Johnson K, Rosenbaum S. et al.: The Health of America's Children: Maternal and Child Health Data Book. Washington, D.C.: Children's Defense Fund, 1988 4. Makinson C: The health consequences of teenage fertility. Fam Plann Perspect 17~3~:132-139, 1985 5. Westoff CF, Calot G. Foster AD: Teenage delivery in developed nations. Fam Plann Perspect 15:105-110, 1983 6. Edelman ED, Pittman KT: Adolescent pregnancy: Black and White. J Commun Health 11(1): 63-69, 1986 7. The Alan Guttmacher Institute: Public concerns about family planning programs in teens. Issues in Brief 5~4), January 1985 8. Smith PB: Sociologic aspects of adolescent fertility and childbearing among Hispanics. J Dev Behav Ped 7(6):346-349, 1986 9. Smith PB, Weinman ML, Mumford DM: Social and affective factors associated with adolescent pregnancy. J Sch Health 90-93, 1982 10. Hayes CD: op. cit., reference 1 11. Louis Harris and Associates, Inc.: Public attitudes about sex education, family planning, and abortion in the United States. New York: Planned Parenthood Federation of America, 1985 12. Lovick SR, Wesson WF: School-Based Clinics: Update. Washington, D.C.: Center for Population Options, 1987 13. Zabin LS, Hirsch MB, Smith EA, et al.: Evaluation of a pregnancy prevention program for urban teenagers. Fam Plann Perspect 18~3~:119-126, 1986 14. Hayes CD: op. cit., reference 1 TESTIFIERS CITED IN CHAPTER 23 003 006 016 021 024 203 215 218 236 246 Balassone, Ma~y Lou; University of Washington 279 Davidson, Ezra; King-Drew Medical Center (Los Angeles) 302 Trostmann, Cathy; Houston, Texas 308 Smith, Peggy B.; Baylor College of Medicine 343 Rose, Jackie; Clackamas County Department of Human Services (Oregon) 360 Kopelman, J. Joshua; The OB-GYN Associates (Denver) 461 Scott, H. Denman; Rhode Island Department of Health 640 Ostergren, Walter; Life Planning/Health Services, Inc. (Dallas) Alden, John; American College of Nurse-Midwives Allensworth, Diane; American School Health Association Batiste, Edna; Detroit Department of Health Blair, Steven; Institute for Aerobics Research (Dallas) Bonta, Diana; Los Angeles Regional Family Planning Council Smith, Richard; Henry Ford Hospital (Detroit) Turnock, Bernard; Illinois Department of Public Health Hanson, Donnie and Vennewitz, Peter; Washington State Department of Social and Health Services Bastien, Deborah; Galveston~ Texas Adolescent Pregnancy 179

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745 F-lores, George; Metropolitan Health District, San Antonio 797 Chater, Shirley; Texas Woman's University 180 Healthy People 2000: Citizens Chart the Course