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ADOLESCENT PREGNANCY AND CHILDBEARING: AN EMERGING RESEARCH FOCUS Cheryl D. Hayes In the past decade, teenage pregnancy and childbearing have become issues of broad public concern. Approximately 1 million adolescent girls become pregnant in the United States every year. While about 400,000 of them obtain abortions, nearly half give birth. The majority of these births are to unmarried mothers, nearly half of whom are under age 18. The United States leads all other Western developed countries in its rates of adolescent pregnancy, abortion, and childbearing, even though the age of initiation and rates of sexual activity in these countries are comparable. The difference is most striking among the youngest teenagers, those under age 15, who are more than five times as likely to give birth as girls in any other developed country of the world. Almost any newspaper or popular journal reminds one of these disturbing facts. The news media has stressed the epidemic nature of adolescent pregnancy. Despite the fact that birth rates among teenagers have actually declined somewhat since 1970, policy makers, professionals, parents, and researchers have debated the meaning of these social and demographic trends and have repeatedly called for immediate responses to the "impending crisis." As a result, the past decade has witnessed an enormous growth in efforts to understand these changing social and demographic patterns. Policies and programs to prevent untimely and unintended pregnancies among teenagers and to overcome the frequently negative social, economic, and health consequences of early childbearing and parenting have also expanded. The process has been iterative. In some cases knowledge has spurred public decision making and the initiation of interventions; in others, the need for action has highlighted and motivated the need for more and better information about factors affecting these behaviors and their outcomes. Efforts to increase knowledge in these areas have been supported both by federal agencies as well as private foundations. In the mid-1970s, the Center for Population Research within the National Institute of Child Health and Human Development (NICHD) targeted adolescent pregnancy as a priority for research support. Over the past 1
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2 decade, the center has administered a broad program of research, including the collection of national survey data on adolescent sexuality, contraceptive use, and pregnancy resolution, as well as analyses of the antecedents and outcomes of these sensitive behaviors. Since 1982, the Office of Adolescent Pregnancy Programs (OAPP) has also supported an array of studies of familial, institutional, and societal influences on early sexual behavior and adoption, as well as the provision of services to pregnant and parenting teenagers. Notably absent from the OAPP agenda, however, have been studies of factors affecting contraceptive use and ways to encourage more diligent use among teenagers who are sexually active. Several private foundations have also played a key role in research and development to address the problems of adolescent pregnancy and childbearing. The Ford Foundation, with a commitment to reduce poverty and ameliorate its devastating effects on minority populations, began in the late 1970s to support several studies of black-white differences in teenage sexual and fertility behavior, the link between early childbearing and welfare dependence, and international comparisons. In partnership with the U.S. Department of Labor, the Ford Foundation initiated a comprehensive services model to enhance the employability and economic self-sufficiency of teenage mothers. The Rockefeller Foundation and the Hewlett Foundation, because of their strong interest in international family planning issues, also began to support research and demonstration activities aimed at exploring factors affecting teenage fertility and ways of enhancing young people's knowledge and use of contraception. Similarly, the Charles Stewart Mott Foundation, because of its commitment to improving the plight of disadvantaged groups, targeted teenage parents as a population in need and established its Too Early Childbearing network of innovative community-based programs to enhance the well-being of teenage mothers and their children. More recently, the W.T. Grant Foundation, because of its interest in adolescent development, the Robert Wood Johnson Foundation, the Glenmede Trust, and the Kaiser Family Foundation, because of their interests in health promotion, and the Carnegie Corporation, because of its interest in the prevention of harm to children, have initiated and supported a variety of research and demonstration activities aimed at pregnancy prevention. In addition, in the past several years, a number of local foundations, sometimes independently and sometimes in partnership with larger national foundations, have supported the initiation of a variety of community-based programs to help reduce the incidence of pregnancy among teenagers and to support the special needs of pregnant and parenting teenagers. Recently, many of these have been specifically aimed at strengthening state and local responses. As a result of these public and private initiatives, there has been a significant expansion of knowledge about adolescent pregnancy and childbearing from a variety of sources. Despite some inconsistencies among these data sets, we now have generally reliable estimates of
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sexual activity, including age of initiation, frequency of intercourse, and partners. Similarly, knowledge of contraceptive use has also increased, including the timing of initiation, methods chosen, patterns of use, and contraceptive failure. Information concerning pregnancies and abortions is believed to be less reliably reported in surveys than that concerning sexual activity and contraception, and therefore estimates of these behaviors should be viewed with greater caution. Data on births, including the type of delivery and the health status of mother and baby, are highly reliable, as are data concerning marriage, educational attainment, and employment status. In contrast, information concerning adoption appears to be the largest gap, since there is currently no national reporting system to collect data on adoptions, including characteristics of the biological mother and father. Although other problems affect current understanding of adolescent pregnancy and childbearing, including the lack of consistency with regard to race and ethnicity across data sources and the difficulty of obtaining information about males and very young teenagers, knowledge about trends in teenage sexual and fertility behavior has greatly improved over the past decade. Similarly, the number and sophistication of studies concerning the consequences of early pregnancy and childbearing have increased dramatically. The variety of social, economic, and health outcomes have been carefully and convincingly documented. We know with certainty that, for the majority of teenage parents and their children, the prospects of a healthy and independent life are significantly reduced. In the absence of adequate nutrition and appropriate prenatal care, teenage mothers are at a heightened risk of pregnancy complications and poor birth outcomes. They are also at a heightened risk of experiencing a subsequent pregnancy and birth while still in their teens. The infants and young children of teenage mothers experience greater health and developmental risks, for example low birthweight, infant mortality, disease and accidents, low IQ, poor school performance, and a variety of social and emotional problems. Teenage marriages, when they occur, are characterized by a high degree of instability. Teenage parents, both male and female, all too often suffer reduced educational attainment and a related limitation of career opportunities. They are at a heightened risk of becoming dependent on public assistance and remaining dependent for longer periods than their peers who delay childbearing into their twenties. And perhaps most disturbing of all, the children of teenage mothers are themselves more likely to become pregnant and give birth as teenagers. Society's economic burden in maintaining these families is substantial--an estimated $16.65 billion in federal outlays for Aid to Families With Dependent Children (AFDC), food stamps, and Medicaid alone in 1985. Knowledge of the antecedents of early pregnancy and childbearing has also grown. A variety of conditions and circumstances have been shown to be associated with these behaviors. Among the most significant are social and economic disadvantage. Young people growing up in families
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4 that have known sustained poverty, whether in urban ghettos or rural areas, become sexually active at a younger age and are therefore at heightened risk of early pregnancy. Those who have grown up in fatherless families and those whose mothers began their own childbearing as a teenager are at a heightened risk of experiencing an untimely and unintended pregnancy. Those who attend racially isolated schools and live in poor, segregated neighborhoods in which early childbearing and single parenthood are familiar patterns are more likely to become sexually active at a young age and experience a pregnancy than are young people living and going to school in more prosperous and racially diverse environments. Moreover, teenage girls who are experiencing academic problems, who have low academic and career expectations, and particularly those who have dropped out of school, appear to be at a heightened risk of becoming pregnant. The younger an adolescent girl is at the time of sexual initiation, the more likely she is to experience a pregnancy as a teenager, both because her exposure to the risk of pregnancy is more prolonged, and because she is more likely to delay obtaining a contraceptive method and less likely to use it effectively, if at all. In the growing number of studies of factors affecting the initiation of sexual activity and contraceptive use, these antecedent conditions have frequently been shown to be associated with teenage pregnancy. But correlation does not establish causation. Although we know with certainty that they go hand in hand, we do not have sufficient evidence to declare that poverty, poor school performance, growing up in a fatherless family, or having a mother who had her first baby as a teenager is a direct cause of adolescent pregnancy. Knowledge of how to reduce the incidence of early, unintended pregnancy and of how to overcome the negative effects of an early birth is far less firm than knowledge of the antecedents and consequences of teenage pregnancy and parenting. The number and variety of preventive and ameliorative interventions has increased dramatically since the mid-1970s. Yet knowledge of what works, for whom, under what circumstances, with what effects, and at what costs has not kept pace with understanding of the behaviors these programs are intended to influence. In part this is because many programs have been launched by creative and enthusiastic service providers who lack the necessary research skills and financial resources to include evaluation in their program design. In addition, the evaluation of human service programs poses numerous theoretical, methodological, and practical problems that inhibit researchers and affect the quality of the results that are obtained. Program evaluations have been scarce, and studies have often failed to identify and examine the range of relevant direct and indirect outcomes. Thus, for example, we don't know the effects on teenage pregnancy rates of interventions to boost school achievement, because fertility outcomes typically have not been studied in assessing
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education programs. In addition, the quality of the results obtained from evaluations of adolescent pregnancy programs has been highly variable, and few impact studies, even those that have been methodologically strong, have been continued over a sufficient period of time to reveal long-term outcomes. As a result, this body of research has frequently failed to yield a firm scientific base on which to build policies and programs. The costs, effects, and effectiveness of few interventions have been clearly demonstrated, although there are two notable exceptions: programs to encourage contraceptive use among sexually active teenagers have been shown to reduce the rate of pregnancy among program participants; and programs to provide prenatal care to pregnant teenagers have been shown to reduce the incidence of pregnancy complications and to improve birth outcomes for young mothers and their babies. Yet program research has provided numerous insights concerning interesting and potentially promising approaches to prevent untimely and unintended pregnancies and to enhance the well-being of adolescent parents and their children that merit further development and evaluation. Among the most promising are programs to enhance life options, those intended to motivate teenagers to avoid pregnancy and parenting at this stage in their lives, by enhancing their academic performance, employability, and goal setting skills. Programs to encourage teenagers to delay sexual initiation similarly require further development and evaluation as a basis for future policy decision making. The chapters of this volume contain the background papers that informed the deliberations of the Panel on Adolescent Pregnancy and Childbearing and support many of its conclusions concerning the current state of knowledge. Chapters 1 through 4 present detailed reviews of the research on factors affecting adolescent sexual decision making, including the initiation of sexual activity, contraceptive use, and pregnancy resolution. Chapters 5 through 8 review the scientific evidence on the short-term and long-term social, economic, and health consequences of early sexual activity, pregnancy, childbearing, and parenting. Chapters 9 and 10 review evidence concerning the costs, effects, and effectiveness of alternative programs. The tables referred to in Chapters 1-10 are found in the statistical appendix. Each of these chapters presents an analytic overview and summary of the available research. Each also includes a critique of the research, speculations about its meanings, and suggestions for needed research, as well as some implications of findings for policies and programs. The authors were selective in their presentation and review of studies. Some, including published articles and books, were judged to be methodologically inadequate, and their inclusion was deemed inappropriate. The appendix to the volume contains a detailed statistical compilation of data on adolescent sexual and fertility behavior from a
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6 variety of sources. Many of these tables have been published elsewhere; others present special analyses of existing data commissioned by the panel to answer key questions that arose in the course of its study. Each table is accompanied by a brief narrative highlighting the key points that emerge from the data. Taken together, these papers and the statistical appendix represent a valuable resource for researchers, policy makers, and program designers, who regularly need information on trends in teenage sexual and fertility behavior, on the antecedents and consequences of pregnancy and childbearing among teenagers, and on the costs, effects, and effectiveness of alternative programmatic strategies.
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