National Academies Press: OpenBook

Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing (1987)

Chapter: 9 Priorities for Policies and Programs

« Previous: 8 Priorities for Data Collection and Research
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 261
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 262
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 263
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 264
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 265
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 266
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 267
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 268
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 269
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 270
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 271
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 272
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 273
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 274
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 275
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 276
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 277
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 278
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 279
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 280
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 281
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 282
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 283
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 284
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 285
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 286
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 287
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 288
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 289
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 290
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 291
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 292
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 293
Suggested Citation:"9 Priorities for Policies and Programs." National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: The National Academies Press. doi: 10.17226/948.
×
Page 294

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

9 Pnonties for Policies and Programs Like many others who have addressed the issues of adolescent preg- nancy and childbearing its recent years, the Pane} on Adolescent Pregnancy and Childbeanng has recognized that the problems are complex and controversial. Solutions unD not be easily or rapidly attained. Although the age of initiation end rates of sexual activity are comparable, the United States leads most other developed countries In the rate of early pregIlan- aes, abortions, and births tO adolescent mothers. Fertility vanes by age, race, and socioeconomic status, but early pregnancy and childbearing are IlOt limited to any single subgroup. They are DOt confined by urban or rural boundaries, nor is their Impact limited tO a single gender or genera- tion. Everyone is affected, directly or Correctly. Adolescent pregnant and childbeanug are issues of broad national concern, and they are issues . . t tat require urgent attention. Regardless of one's political philosophy or moral perspective, the basic facts are disturbing: more than ~ million adolescents become pregnant each year. Just over 400,000 teenagers obtain abortions, and nearly 470,000 give birth. The majonty of these births are to unmarried moth- ers, nearly half of whom have not yet reached their eighteenth birthday. For teenage parents and their children, prospects for a healthy and independent life are significantly reduced. Young mothers, ~ the absence Of adequate nutntion and appropriate prenatal health rare, are at a height- ened risk of pregnancy complications and poor both outcomes; they are also more likely tO experience a subsequent pregnancy while still ~ their teens. The infants of teenage mothers also face greater health risks, ~nclud 26~

262 ADOL~SCEN-T SEXUALITY PREGNANCY AND CHILDBEARING ing low birthweight, accidents, illness, and infant mortality. Teenage mamages, when they occur, are characterized by a high degree of instabil- ity. In addition, teenage parents, both female and male, suffer the negative impact that untunely parenting has on their educational attainment and the related limitation of career opportunities. Teenage parents are more likely than those who delay childbeanng to experience serious unempioy- ment and inadequate income. Because these young people often fare poorly in the workplace, they aIld their children are highly likely to become dependent on public assistance and to remain dependent longer. Somety's economic burden in sustaining these families is substantial. Why do young people who are hardly more than children themselves become parents? Is it due to a lack of individual responsibility, matunty, knowledge, and values? Or does it result from the pervasive problems associated with poverty, including limited education and employment opportunities, and among many high-nsk youth, growing up in a father- less family? The answer to both of these questions seems to be yes. The causes of teenage pregnancy are varied and complex, and tO a large extent the issues of individual responsibility and social environment are mterre- {ate3. For this reason, the panel has studied and addressed the problems with both individual and societal perspectives in mind. On the basis of two years of rewew, analysis, and debate, the panel has reached six general conclusions, which underlie all of itS specific cor~clu- sions and recommendations for policies and programs: I. Prevention of adolescent pregnancy should have the highest pnonty. In both human and monetary tens, it iS less costly to prevent pregnancy than tO cope with itS consequences; and it is less expensive to prevent a repeat pregnancy than to treat the compounded problems. 2. Sexually active teenagers, both boys and girls, need the ability to avoid pregnancy and the motivation tO 60 SO. Early, regular, and effective contraceptive use results In fewer unintended pregnancies. Delaying the Initiation of sexual activity will also reduce the~ncidence of pregnancy, but we currently know very little about how to effectively discourage unmar- ried teenagers Tom initiating intercourse. Most young people do become sexually active during their teenage years. Therefore, making contracep- nve methods available and accessible to those who are sexually active and encouraging them tO diligently use these methods is the surest strategy for pregnancy prevention. 3. Society must adroit treating adolescent pregnancy as a problem peculiar to teenage girls. Our concept of the high-nsk population must

PRIORITIES FOR POLICIES AND PROGRAMS 263 include boys. Their attitudes, motivations, and behavior are as central to the problems as those of they female partners, and they must also be central to the solutions. 4. There is no single approach or quick fix to solving all the problems of early unintended pregnancy and childbearing. We will continue to need a comprehensive array of policies and programs targeted to the special characteristics of commun3 ties and to the circumstances of teenagers from different social, cultural, and economic backgrounds and of different ages. Because adolescents are not a monolithic group, they do not a] experience sexual activity, pregnancy, and childbean~g In the same way. Our broad goal is the same for all young people: that they develop the necessary capabilities to make and carry out responsible decisions about their sexual and fertility behavior. The strategies for achieving these goals and the specific interventions to carry them out, however, should be sensitive to differences In values, attitudes, and experiences among individuals and groups. 5. If trade-offs are to be made in addressing the special needs of one group over another, priority should be given to those for whom the consequences of an early unintended pregnancy and birth are likely to be most severe: young adolescents and those from the most socially and economically disadvantaged backgrounds. In many ways those at highest risk are hardest to serve, yet they are also the groups that have been shown to benefit most. 6. Responsibility for addressing the problems of adolescent pregnancy and childbearing should be shared among m~induals, families, voluntary org~7~ations, communities, and governments. In the Unite] States, we place a high priority on ensuring the rights of ~ndinduals to hold different values and the rights of families to raise their children according to their own beliefs. Therefore, public policies should affirm the role and respons~- bility of families to teach human values. Federal and state governments and community institutions should supplement rather than detract from that role. The prevalence of adolescent pregnancy and childbearing is weL docu- mented. Knowledge about the causes and consequences of these behaviors has greatly expanded over the past decade and a half. Knowledge from the growing body of evaluation literature and accumulated intervention expe- nence, though incomplete in many respects, suggests opportunities and directions for policies and programs aimed at sobering these problems. In the remainder of this chapter we present specific conclusions and recom

264 ADOLESCENT SEXUALITY; PREGNANCY AND CHILDBEARING mendations within a basic framework for establishing policy goals, identi- fying alternative strategies to achieve these goals, and selecting specific programmatic approaches to carry out these strategies. PRIORITIES FOR POLICIES AND PROGRAMS The panel's conclusions and recommendations cover a range of actim- ties that includes research, planning, policy development, service delivery, and monitoring. Some of the specific actions we propose would involve steps by federal, state, and local policy makers to enact new legislation or direct the agencies under their jurisdiction to undertake new initiatives. Others would require the continuation or intensification of public and private efforts already under way. When existing knowledge supports new or revised policies and programs or highlights the effectiveness of . . . . . ,. . Ongoing 1mtlatlves, we propose specific new or continues programs or specific agenda for research and development. When existing knowledge provides insights but is incomplete, we advise further demonstration and evaluation to enhance understanding of the relative COStS, effects, and effectiveness of promising approaches. When innovative policies have been indicated but there are as yet no scientifically measurable outcomes, we urge carefid observation and mon~tonng. Many of our recommenda- tions build on policies, programs, and research that are already under way. Many reinforce the priorities of other individuals and groups that are addressing these complex and controversial issues of adolescent pregnancy. The panel has identified three overarching policy goals, presented in order of prionty, that provide a framework for our specific conclusions and recommendations: 1. Reduce the rate and incidence of umntended pregnancy among adolescents, especially among school-age teenagers. 2. Provide alternatives to adolescent childbearing and parenting. 3. Promote positive social, economic, health, and developmental out- comes for adolescent parents and their children. For most young people in the United States, realizing fuming adult work and family roles depends on completing an education and entering the labor force before becoming a parent. Many do delay the in~tiai~on of sexual acidity until after they have graduated from high school, pursued postsecondary education or gained work experience or both, and perhaps married. Many others become sexually active before they have passed these

PRIORITIES FOR POLICIES AND PROGRAMS 265 milestones in the transition from adolescence to adulthood. Regardless of the timing they choose for initiation of sexual activity, however, all adolescents need the ability and the motivation to avoid becoming parents before they are socially, emotionally, and economically prepared. As a society, our approach to pregnancy prevention must be targeted to the complex social, emotional, and physical needs of all adolescents. Preg- nancy prevention strategies must provide teenagers the necessary support and encouragement to strive for fulfilling, productive adult roles in addi- iIon to parenthood. Despite the amount of energy and resources that are devoted to prever~- tion strategies, however, some teenagers will experience unintended and untimely pregnancies Given the potentially adverse consequences of early parenting for the life chances of these young people, there should be alternatives to childbeanng and childrearing. Abortion is a legal option for all women, including adolescents. We acknowledge that voluntary termi- nation of pregnancy is controversial, and for many in our society it iS morally reprehensible. Although we strongly prefer prevention of preg- nancy to avoid parenthood, abortion is an alternative for teenagers for whom prevention fails. Adoption is also available to those teenagers who choose not to voluntarily terminate their pregnancies yet are unable or unwilling to assume the ~11 responsibilities of parenting. Finally, for teenagers who choose to bear and to raise their children themselves, supports and services to promote healthy development, re- sponsible parenting, educational attainment, and economic self- sufEc~ency should be available. Indeed, investing In the quality of life of teenage parents, their families, and their children may be the first step toward preventing early unintended pregnancies in the next generation. Inherent ~ this policy Framework for addressing the problems of ado- lescent pregnancy and childbeanug is a sigIliEcant dilemma. In placing the highest pnonty on prevention, we do not mean tO diminish the significant need for supports and services for pregnant and parenting teenagers. Yet, remedial responses, however effective, do not address the basic needs of young people who have not become sexually active and who have not expenenced pregnancy. And some have raised concerns that policies and programs that offer support and assistance only after a pregnancy has occurred may even have created the wrong incentives, especially for those from severely disadvantaged backgrounds. Ad young people, regardless of whether they are teenage parents, need tO be encouraged tO develop positive perceptions of what their lives can be. They need opportunities tO

266 ADOLESCEN T SEXUALITY PREGNANCY AND CHILDBEARING achieve their goals, and they need support an] assistance from their families and their communities to become healthy, productive adult mem- bers of society. Goal 1: Reduce the Rate and Incidence of Unintended Pregnancy Among Adlolescents, Especially Among School-Age Teenagers The panel is unequivocal in its conviction that the primary goal of policy makers, professionals, parents, and teenagers should be a reduction in the rate and incidence of unintencled pregnancy among adolescents, espectaDy among school-age teenagers. Pregnancy prevention would result not only in fewer births but also in fewer abortions to teenagers. Although an ur~planned pregnancy can have seriously negative conse- quences at age 18 or 19 among those who have completed high school, it is likely to present even greater hurdles for younger teenagers. When preg- nancy results in childbeanng, it increases the probability that adolescent parents will drop out of school and reduces the probability that they will complete high school or pursue postsecondary education. Early childbear- ing is also associated with larger family size. For these reasons, younger teenage parents are often vulnerable to an array of adverse social and economic consequences, which we have discussed In detail in this report. In addition, the younger the teenage mother at the rime of birth, the higher the average estimated public costs of her childbeanng and the higher the estimated potential savings of her postponing that birth. The panel has identified three general strategies that con lead to a reduction in the rate of early pregnancy: enhance the life options of disadvantaged teenagers, `delay the initiation of sexual activity, and en- courage contraceptive use by sexually active teenagers. Central to all of them is the need for teenagers themselves to embrace values that lead to responsible, healthy, and productive lives, including the avoidance of unplanned and untimely parenting, and to be steadfast In their belief that they can achieve their goals. Parents and family members can and should play a key role in helping young people, both male and female, acquire and retain these values. But indiv3 duel and family values are influenced by community and societal norms: therefore, the community as a whole must reinforce and support in~im~ual and family efforts to discourage early pregnancy and encourage adult self-su~ciency. Enhance Lithe Oprior~s Poverty and hopelessness, which exacerbate many social problems, play an especially important role in the problems

PRIORITIES FOR POLICIES AND PROGRAMS 267 associated with adolescent pregnancy. Sexual activity and pregnancy among teenagers are not confined by race and income, yet the correlation between poverty and adolescent fertility is well documented. Nationally, more than half of Aid to Families With Dependent Children (AFDC) benefits support families in which the mother gave birth as a teenager. The median income of families headed by women under the age of 25 is below the poverty level, and approximately three-quarters of all such families live in poverty. Research has shown the deleterious effects of poverty on those caught in its cycle: attitudes offatalism, powerlessness, alienation, and helpless- ness that are perpetuated from one generation to the next. For tOO many high-risk teenagers, there are too few disincentives to early childbearing. Inadequate basic skills, poor employment prospects, and few successful role models for overcoming the overwhelmingly negative odds of in- tergenerational poverty have stifled the motivation of many to delay immediate gratification and avoid pregnancy. Teenagers need a reason to believe that parenthood is inappropriate at this point in their lives. Accordingly, one important strategy for reduc- ing early unplanned pregnancy is to enhance their life options, by en- couraging them to establish career goals in addition tO parenthood and by helping them understand the value of educational attainment and employability skills. This strategy is aimed at reducing adolescent fertil- ity by nurturing the motivation to prevent untimely and unplanned parenthood. We lack program research that clearly demonstrates the effectiveness of this strategy for reducing early pregnancy. Nevertheless, we outIme below several interventions that seem promising and merit farther de- velopment and evaluation. Life-planning courses Helping teenagers to understand the seriously negative consequences of an unplanned birth for their present and future lives may be an important component of developing motivation. Life- plann3ng courses are aimed at helping high-risk teenagers identify educa- tion, career, and family options, develop life plans and goals, and under- stand how early childbearing might affect the* ability to achieve those goals. Programs of this type have been smaD-scale, and there is little deEninve evidence oftheir success. Early returns, however, suggest that this may be a promising approach. Intervention models of this type need further development and evaluation. In particular, attention Is sleeked on

268 ADOLESCENT SEXUALITY PREGNA.NCY AND CHILDBEARING the related supports and services that are necessary to help teenagers effectively use the information, planning, and decision-making skills they can gain in life-planning courses. Programs to improve school performance Boosting school achieve- ment and preventing school dropout may also be a promising approach to reduce early umOten~e] childbearing among school-age teenagers. Teenage pregnancy rates have been shown to be higher among poor achievers. Poor school performance negatively affects self-concept and motivation. It also has adverse eRects on later employment opportuni- t~es. As many researchers, sernce providers, and advocates have observed, educational opportunity and achievement are key to helping high-nsk teenagers develop execrated expectations, a sense of can-do, and the basic skips necessary to achieve their goals. Although developing afuD agenda of educational refonn was not within the mandate or expertise of the panel, we highlight the need for educational interventions whether alternative schools or special programs in regular schools-to overcome the educational problems and ~e~clenaes of many young people. in particular, such programs need to identify high-risk students early in the* educational careers and provide the remediation required to ensure that they develop essential basic skids and achieve smooth education-to- work transitions. Although research has not specifically linked pro- grams to improve school performance with reductions in adolescent pregnancy, such programs merit further development and evaluation to assess their potential effects on fertility. Employment programs Chronic unemployment and poorjob pros- pects among some subgroups of the population have had serious adverse eRects on many young people's perceptions of opportunity. The lack of meaningful employment options may diminish the motivation to delay parenthood. As with educational refonn, the development of a compre- hensive plan for youth employment is beyond the mandate and expertise of the panel, yet we emphasize the need to enhance the employability of high-nsk youth by providing them with i~ors~ation concerning career alternatives, by teaching job skills and job search skills, and by helping them gain work experience while completing their educations. Again, although research has not specifically linked youth employment pro- grams to reductions in adolescent pregnancy, such programs merit fur

PRIORITIES FOR POLICIES AND PROGRAMS 269 ther development and evaluation to assess their potential effects on fertility. Role models All young people adopt role models-whether in their . families, among their peers, or in their communities that significantly influence their developing values, attitudes, and behavior. Prov3 ding high-nsk teenagers with positive examples on which to model their behavior may help them form aspirations, expectations, and activity patterns that match desired norms. Role mode] and mentonug pro- grams are intended to help teenagers see in others what they can become themselves. Most emphasize the importance of educations attainment, employability, and responsible sexual and fertility behavior. These inter- ventions are relatively new and to date most have been small in scale. As a result, there is no definitive evidence of their success in reducing early nmutended pregnancy, yet they ment further examination and trial. Delay Sexual Initiation A second strategy for reducing the rate of teenage pregnancy is to help teenagers, both male and female, develop ways to postpone sexual initiation until they are capable of making wise and responsible decisions concerning their personal lives anti family formation. For young teenagers especially, pregnancy and parenthood are often distant, intangible abstractions. Relating sexual decisions to lifelong consequences is difficult. Adolescents who cannot conceptually link current behavior to future contingencies are often unreliable users of contraceptive methods. For them, efforts directed at discouraging the iIiitiation of sexual activity may be an appropriate means of reducing umOten~e] pregnancy. Essential to the success of this strategy are the acquisition of probiem-solv~ng and communication skills, understand- ing of the personal and societal consequences of unprotected sexual acidity, and knowledge of how to act responsibly. Enhancing life op- tions, which has been discussed above, may also encourage teenagers to delay the initiation of sexual acunty. Several interventions have the potential for helping young people delay the initiation of sexual activity, although there is little available endence at this time to document their effectiveness. Sex education and family life education Courses that provide wfor- mation about sexuality and family roles and interactions have been shown to increase students' knowledge of reproduction and the proba -

270 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING ble consequences of sexual activity without contraception. Although these courses are widely available in school systems nationwide, they crazy substantially in their content, their comprehensiveness, and the quality of instruction. They also vary in the extent of parent and com- mum~y involvement in their planning and implementation. In addition, few school districts have programs that are directed at children of ele- mentary school age. While knowledge alone cannot be expected to alter adolescent behavior, education programs that are combined with other approaches, such as assertiveness and decision-making training and role modeling, may help reinforce family values, responsible behavior, and self-control with regard to sexual activity. Similarly, age-appropnate education programs that provide young children with information con- cerning sexuality and sex abuse, as well as training to deal with poten- tiaDy abusive encounters, may help reduce their anxieties and fears about personal sexual development and improve their ability to avoid sexual exploitation. Unfortunately, program research to date has not pronded conclusive evidence of the impact of sex and family life education on the . . . . .. . tang o: : sexua . Stratton. Assertiveness and decision-making training Programs that teach ad- olescents problem-soinng, decision-making, and interpersonal commu- nication skills are sometimes aimed at promoting sexual abstinence by counseling younger adolescent boys and girls on how to resist pressures to become sexually active before they are ready. An evaluation of one program using this approach is now under way. If the results of that study are positive, replications and adaptations of this program mode! may be warranted. Role models Many adolescents learn by example; they are attracted to real and fictional characters who seem powerful and successful. Soa- ety's response to the behavior of those models helps young people to develop expectations for their own behavior and the behavior of others and to cianf y their personal values. When role models exemplify societal ideals, the process can potentially have positive effects on adolescents' attitudes, motivations, end behaviors, including sexualbehanor. Several interventions using peer counselors, mentors, and adult community volunteers to work on a one-to-one basis with high-risk teenagers are now berg tested. Among the tasks of the role models is to help teenag- ers find activities other than sexual ones that can Fife they needs for

PRIORITIES FOR POLICIES AND PROGRA.~S 271 emotional gratification, for example, SportS and community service. If the results of these efforts show positive effects on delay of sexual initiation, replications and adaptations of this approach may be war- ranted. Media treatment of sexuality Among the most pervasive influences on adolescents are the personalities and heroes of television, movies, and rock music. The exploitation of sex, aggression, and violence in media programming and advertising has become a central issue for many indi- viduals and groups concerned about adolescent pregnancy and childbear- ing (e.g., the Children's Defense Fund, the National Urban League, the Center for Population Options, and several state and local coalitions and task forces). Some of these groups are exploring ways to encourage the media to present more realistic and responsible portrayals of personal and sexual relationships among adult heroes and to discourage sexual activity and parenting among young adolescents. Because most of these efforts are in preliminary stages, it is too early to assess their effects on program- ming content and advertising approaches. Indeed, the incentives for network executives to alter they current messages and models are weak. Nevertheless, multiple coordinated efforts at the community level and at the national level to exert pressure may have greater potential for e~ect- ing change than isolated appeals. Encourage Contraception The panel's research has established that the most effective intervention for reducing early unintended pregnancy in sexually active teenagers is diligent contraceptive use. Male contracep- tion, as we] as mate support for female contraception, is essential. Adolescents who practice contraception are less likely to experience an unplanned pregnancy than those who do not; those who rely on the contraceptive piD are less likely to conceive than those who use noupre- scnption methods. Although modem contraceptive technology, espe- c~ally the pill, may have contnbuted to the liberalization of societal sexual attitudes and practices, which In turn have influenced adolescent behavior, there is no evidence that the availability of contraceptive services per se has caused increased sexual activity among teenagers, mate or female. In fact, studies show that many adolescent girls are sexually active a year or more before they obtain contraceptives. This pattern must be changed in order to reduce the incidence of early unintended pregnancy and ultimately the more painful, hazardous, and disruptive

272 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING alternatives of abortion or untimely childbeanng. The pane] recognizes that contraception alone cannot control adolescent fertility, but it is a necessary step. Given current contraceptive technology, the pill and the condom are the most promising methods for adolescents, whose menstrual cycles may be irregular and whose patterns of sexual activity may be sporadic. For women under age 25 who do not smoke, pill use carries a Tower risk of health complications and death than any method except for Lamer methods. When used appropriately, the pill has the lowest rate of contra- cepti~re failure next to sterilization. For adolescent girls who smoke, the health risks associated with piL use are somewhat greater but Stiii less than the risks of an unintended pregnancy and childbirth. For girls who smoke and for those who have intercourse infrequently, the condom is the best alternative. The primary health risks associated with condom use are those that result from method failure. Condom failure rates are greater than those associated with pill use, but significantly less than other barrier methods or periodic abstinence. Despite these facts, adolescents are frequently deterred from use of the contraceptive pill and the condom by misunderstandings about their unintended consequences, including exaggerations of the health risks and unpleasant side effects associated with the pill and of the diminution of pleasure from condom use. Efforts should be made by parents, profes- sionals, and the media tO correct these misunderstandings. In addition, contraceptive programs should include or be linked to appropriate health and sex education aimed at teaching adolescents about the risks (includ- ing the risks of contraceptive failure) associated with alternative contra- ceptive methods and how to obtain and appropriately use these methods. Apprehensiveness about the health care system and the diagnostic proce- dures (e.g., the pelvic examination and invasive laboratory tests) assoa- ated with contraceptive services may be a barrier preventing some teen- agers from coming to a clinic. Although such procedures have become Seward practice, it would be useful to explore nonmedical models for the distribution of contraceptive methods, including the pin. The pane] concludes that use of the contraceptive pill is the safest and most effective means of birth controlfor sexually active adolescents. Aggressive public education IS neelelto dispel myths about the health risks of pilluse by girls in this age group, and contraceptive serviceprogra~c should explore nonmedical models for 12stnbutio?' of the pill. -

PRIORITIES FOR POLICIES AND PROGRAMS 273 The availability of contraceptive services to adolescents depends heav- ily on public support, ~ particular funding through Title X of the Public Health Services Act, Medicaid, and other federal and state maternal and child health programs. In light of the demonstrated effectiveness of contraceptive use in reducing early unintended pregnancy, continued support of these programs is essential. To the extent that it is possible, these programs should minimize bureaucratic, geographic, and financial barriers that may deter sexually active adolescents from seeking contra . . ceptlve services. The panel cor~clules that, to make this strategy effective, there must be continuelpublicsupportfor contraceptive cervices to adolescents, such as has been suppliedprimarily through TitleXoftheFamilyPlanningServicesanlPopula- tion Research Act, Medicaid, and other federal and state maternal and chill health programs. Such programs should minimize potential bamers of cost, convenience, and confidentiality. Several interventions have been shown to encourage diligent contra- ceptive use among sexually active teenagers. Sex education Sex education courses vary In their attention to and treatment of contraception. In several European countnes, however, sex education that provides information concerning contraceptive methods, including how to obtain them and how to use them, is associated with earlier and more diligent contraceptive use by adolescents, espeaaDy use of the pill. The panel urges that sex e2;`catior' programs include information or: methods of contraception, how to use them, and how to obtain them. Contraceptive services There are numerous models for delivenug contraceptive services to teenagers, both boys and girls, and services are available from a variety of prodders; ~nclud7mg public health depart- ments; hospital-, community-, and school-based clinics; Inmate pro- vipers; and drugstores. For reasons of cost and confidentiality, teenagers are more likely to seek services from cynic facilities than from private physicians. Se~rerai components of the approaches that clinics take to deal with adolescent clients appear to affect the patterns of attendance of sexually active teenagers: (~) aggressive outreach and follow-up, to reach sexually active teenagers who may not have sought contraceptive serv

274 ADOLESCENT SEXUALITY; PREGNANCY; AND CHILDBEARING ices, through public information programs, sex education programs, and close links to community youth service organizations that can refer young clients; through assistance in getting them to the clinic; and through monitoring their success in using their chosen contraceptive method; (2) instruction about venous contraceptive methods, including their risks and benefits, and the consequences of ineffective or inappro- pnate use; (3) counseling to help teenagers make responsible decisions about contraception and to help them fee] they have some commitment to their chosen method; and (4) sensitivity to the special concerns and apprehensions of teenagers ire coming to family planing cynics. In order to encourage contraceptive use among sexually active teenag- ers with diffenng needs and predispositions to use contraceptive services, numerous models and approaches should continue to be available and accessible to teenagers from a variety of service providers. Cost should not be ~ barrier to receiving contraceptive seances. Thepanel urges continuedsupportfor a variety of contraceptive service models including private physicians to reach adolescents. Contraceptive services should be available to all teenagers at low or no cost. Clinic service providers' whether based in hospitals, public health departments, private clinics, or commu- nity service organizations, should make efforts lo improve the effectiveness of their programs by (1) enhancing their outreach efforts to encourage earlier use of contraceptive methods; (2) exploring more effective counseling approaches to encourage compliance; and (3) enhancing theirfollow-up of clinic patients to track their contraceptive use. Two program models for providing contraceptive services to adoles- cents are of special interest in this regard. F=st, school-based climes that pronde teenagers with contraceptive services in the context of compre- hensive adolescent health care have the potential to reach a large number of boys and girls under age 18. Most school-age adolescents are enrobed in school, and reproductive health services in this setting may be more accessible to them than those provided by more traditional family plan- n~ng clinics. Because boys attend school-based clinics for other health care needs, such as athletic physicals, these programs may also hold greater potential for encouraging male involvement in contraception than more traditional [emale-onented family planning facilities. In these settings, teenagers are also more accessible to clinic staff for purposes of outreach and follow-up. School-based clinics do have some limitations,

PRIORITIES FOR POLICIES AND PROGRAMS 275 most important that they generally operate on school schedules and that they are typically not open to students who have dropped out or gradu- ated from high school. Nevertheless, they represent a promising inter- ~rention for reducing early unintended pregnancy among enrobed stu- ~ents, especially those in junior and senior high schools with large, high-nsk populations. Because school-based clinics are still relatively new and experimental interventions, they require careful evaluation to determine their effects and effectiveness, including possible undesirable side effects (e.g., community resistance and increased rates of early sexual activity). Decisions concerning the establishment of school-based clinics should rest with local communities and their school systems. The pane] concludes that school systems, in cooperation with various health care and youth-serving agencies, shoul~further develop arid refine comprehensive sekooi-based clinic models for implementation and evaluation in schools with large, high-nsk populations. Second, condom distribution programs aimed specifically at young men represent another potentially promising means of encouraging mate involvement in pregnancy prevention. As previously discussed, efforts to distribute condoms to sexually active adolescent males and instruct them on proper use can be sponsored by a variety of health and social service organizations. Because they do not require special clime facilities, these programs can more easily reach out to their target population by establishing distribution centers in the places where teenage boys con- gregate (e.g., youth centers, gyms, video arcades). In addition, data show that many sexually active adolescent girls, who delay obtaining prescription contraceptive methods after initiating intercourse, fre- quently rely on male methods in the intenm. Consequently, promoting condom use among young men may result in greater use of contracep- tion by teenagers at fast intercourse or soon thereafter. Condom use has the added benefit of prodding protection against sexually transmitted diseases. There is little program research that has explored the effects and effectiveness of different models for condom distnbution among young men ~ the United States. In light of what is known about patterns of con~acepi~ve use by adolescent boys and girls, however, elbows should be launched to develop and evaluate distribution programs. The panel recommends the development, implementation, and evaluation of condom distribution programs.

276 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING Contraceptive advertising Historically, teiewsion networks and ra- dio stations have been resistant to advertising contraceptive methods. Yet studies of factors affecting attitudes and contraceptive behavior in European countries suggest that contraceptive advertising may be one means of increasing teenagers' awareness of cor~traceptive methods and making them fee! that these methods are accessible. There is no evidence to suggest that advertising alone will directly alter behavior; however, the potential of the media through programrn~ng and advertising to influence teenagers' attitudes about desirable models for behavior, in- cluding sexuality, is significant. The panel concludes that efforts should be undertaken to develop and test the effects on contraceptive use and uninterested pregnancy of paid promotional messages for contraceptives that are directed at sexually active adolescents. Goal 2: Provide Alternatives to Adolescent Childbeanug and Parenting The pane! believes prevention of pregnancy through abstinence or contraception is far preferable to unintended pregnancy among teenag- ers. Yet there is little evidence that available prevention strategies signi~S- cantly influence the timing of sexual initiation, and, although improved use of contraception would definitely reduce the incidence, it would not eliminate teenage pregnancy altogether. It would thus be disingenuous to shrink from consideration of the difficult choices facing the nearly ~ minion teenagers who become pregnant each year. The options con- fros~t~g the unmarried pregnant child or woman are (~) terminating the pregnancy, (2) bearing the child and raising it, and (3) relinquishing the child for adoption. In round numbers, 400,000 Iris per year choose abortion, 458,000 keep their babies, and 12,000 choose adoption. The panel has therefore examined each of these alternatives. Abortion In ~1973 the Supreme Court made abortion a legal option for all women in the United States. Despite this fact, abortion remains controversial. its use by adolescents is espec~aDy charged, because it raises significant unresolved issues about the appropriate relationship between the rights aIld interests of an individual adolescent, her family, aIld the state. Several states in recent years have restricted minors' access to abortion services without parental consent or judicial bypass of parental consent.

PRIORITIES FOR POLICIES AND PROGRAMS 277 Although abortion for very young teenagers remains . . ~. . . . a special issue, there is no empirical evidence concerning the cognitive capacity of adolescents to make such decisions or the psychological consequences of abortion that would either support or redate such age restrictions. On the basis of existing research, therefore, the contention that adolescents are unlikely or unable to make weD-reasoned decisions or that they are especially vulnerable to serious psychological harm as a result of an abortion is not supported. On the contrary, research has shown that for most abortion patients, including adolescents, relief is a frequent reac- tion. Nor has research documented that legally required parental involve- ment helps teenage girls cope better with their choice to terminate the pregnancy. There is no evidence that it reduces the probability of subse- quent unwanted pregnancies or serves any other purpose than to ensure that parents are aware of what their adolescent daughters are doing. There is, however, growing evidence that parental consent statutes cause teenagers to delay their abortions, if for no other reason than that they must undergo the de facto waiting period associated with eluding a lawyer and gaming access to the courts. These delays may increase the health risks involved if they result in postponements until the second trimester of pregnancy. There is also growing evidence that many adoles- cents ~ states with these statutes are traveling to nearby states to obtain sernces rather than go through the judicial bypass procedure. It is not currently known, however, whether such statutes are causing an in- crease in unwanted births to teenagers. Research is needed to address these Occult issues. In addition, no research has been conducted to Steins whether "matunty" (the legal standard for granting a judicial bypass to a mirror adolescent seeking an abortion without parental consent) can be reliably and validly assessed. In the absence of clear legal standards for maturity, such assessments run the risk of being inconsistently interpreted and applied, as well as being inaccurate. Along with other legal scholars and professional psychologists who have considered this issue, the pane! questions whether a "mature minor" standard can be effectively imple- mented. The question has been raised of whether the availability of abortion has undermined delay or contraception. While it is true that adolescent girls in the early phase of sexual activity often do not use contraception regularly, we have found no evidence that abortion is used preferentially

218 ADOLESCENT SEX UALI7) PREGNANCy AND CHILDBEARING to abstinence or contraception as a means of avoiding unwanted child- beanng. Repeat abortions do occur among teenagers as well as among adult women. However, concern that the availability of abortion serv- ices will lead to higher rates of teenage sexual activity an] pregnancy and less reliance on contraception is not supported by the available research. Adolescents who have had abortions are in fact less likely to experience a repeat pregnancy within two years than those who have given birth. Most abortions occur during the first trimester of pregnancy and therefore carry little risk of medical complications when they are per- fo~ed by qualified professionals in appropriately equipped settings. Although the health risks are somewhat greater for second trimester abortions, when perfonned under appropriate conditions these risks are minimized. In general, the health risks associated with an early, legal abortion are no greater for adolescents than for adult women, and they are also less significant than the risks associate] with pregnancy and childbirth. Public health experts estimate that the replacement of umn- tended births and illegal abortions with legal abortions has averted as many as i,500 preguancy-related deaths among American women (in- cluding teenagers) since 1973 and life-threatenin~ complications in the tens of thousands. ~Or The role of abortion in society's approach to teenage pregnancy is probably the most contentious issue of all. it is impossible to isolate the decision conceming whether to terminate a pregnancy from innumera- ble political, religious, ethicad, and personal considerations, but these are not subject to the kind of scientific inquiry we have made. The panel believes, however, that certain statements about abortion are fui~yjusti- Hed by a combination of scientific evidence and general medical pnnci- ples, and that to avoid thefacts (as distinct from aposition) is intellectually unsound. The panel urges that at each step along the path from sexual initiation to parenting regardless of whether one might wish that that step had not beer: reached the girl or woman should Retreated with thesamelignity, confilential- ity, kindness, and! excellence of health care that are dine any patient. The panel concludes that there is at present no scientific basisfor restricting the availability of abortion to adolescents. Evidence shows that to require minor teenagers to seek parental consent of ten causes them to relay abortions, with attendant health aisles. On this basis, the panel concludes that minor adolescents

PRIORITIES FOR POLICIES AND PROGRAMS 279 should be er~courarel but not required to involve their parents and partners in the decision-making process. --( ~- -- ~1 - ~- - ~' The panel believes there should be rzo compromise in the medical anl personal supportive care of the 400,000 adolescents who have an abortion each year. For those adolescents who choose to terminate their pregnancy, abortion services should include both decision counseling and contraceptive counseling. Several interventions can enhance the availability and accessibility of abortion tO adolescents. Pregnancy testing and counseling Early confirmation of pregnancy is essential to presence a young woman's options for its resolution and to m~r~imize the health risks associated Ninth abortion if she decides to terminate her pregnancy. Cost and confidentiality are important factors affecting where and when teenagers go for pregnancy testing. Because many adolescent girls' first nsit to a family planning clinic is for preg- nancy testing' outreach to encourage them to seek help early may affect the tuning of their visit. Pregnancy counseling to outline the available options for pregnancy resolution should also be pronded as early as possible. In this regard, adherence to principles of voluntansm and informed consent require that facilities provide their clients, including adolescents, with a full account of the possible risks, benefits, and consequences of maternity, abortion, and adoption as well as the appro- priate referral. Teens should be encouraged whenever possible to mvolve their parents and partners in the deasion-making process. Abortion services Abortions are available in hospitals freestanding abortion clinics (nonprofit and for-pro~t), and ~ private physicians' offices. Factors of cost and confidentiality lead most teenagers to clinics for services. Although some climes refer second-trimester patients to a hospital or private physician, and some have adopted parental consent requirements for minor adolescents, most wiB serve teenagers on they own authonty. Abortion counseling, includ3mg helping a young women explore the factors relevant to an formed decision about the ternuna- iron of her pregnancy, is Important for abortion patients, espemaDy young adolescents. Such counseling is likely to enhance the decision- making process and to minimize the emotional strain. Clinics should also encourage minors tO mvolve their partners and parents In their decisions. Counseling for the parents (or other adult family members) of

280 ADOLESCENT SEXUALITY; PREGNANCY AND CHILDBEARING adolescent patients is not typically provided by abortion clinics but may be a useful way of enhancing the family's capability to pronde emotional support. Contraceptive counseling is also an important component of abortion services to advise patients how soon after the procedure they will be at risk of pregnancy, to provide information on contraceptive methods, and to help patients obtain those methods. A`oprior' For some teenagers, becoming a parent is not ~ viable option for pregnancy resolution. For those who lack the resources and motivation tO undertake the significant responsibility of raising a child at that point ~ their lives, alternatives to parenthood are needed. Although adoption seems to have declined in popuianty over the past two decades, especially since the nationwide legalization of abortion, the panel recog- nizes that the development or strengthening of adoption services is needed for those who choose tO relinquish their children. As we have noted elsewhere in this report, research on the adoption decision-making process, as well as on the characteristics and special needs of pregnant adolescents who make adoption plans, is missing. Obviously, such re- search is a first necessary step tO improving the quality of relevant services or developing new ones. The panel recommends that relevant public agencies, in cooperation with the private sector, explore ways of strengthening aloptior' services, including (1J improved recision counseling for pregnant teenagers and (2) development of effective morels for providing comprehensive care to pregnant girls who choose adoption as an alternative to parenthood. Two existing interventions are especially relevant as composts of strategies to support adoption as a nabie option tO parenthood. Pregnancy counseling and referral Teenagers who experience an unintended pregnancy should receive objective, nonjudgmental counsel- ing to inform them of aD their options for pregnancy resolution and the associated risks and beneSts of each abortion, parenthood, and adop- tion. Such counseling should also include decision counseling to help pregnant girls explore their reasons for choosing one course of action over another. Pregnancy counseling can play an important role in teen- agers' decisions concerning pregnant resolution and their later satisfac

PRIORITIES FOR POLICIES AND PROGRAMS 281 tion with those decisions. Pregnant teenagers should be encouraged to involve their partners and parents In the decision-making process. Adoption services For those who elect to carry their pregnancies to term and relinquish their infants for adoption, services should meet the range of physical health care needs and psychological and social supports that these young women need during their pregnancy, during labor and delivery, and after their infants are born and have been placed with adoptive families. Although research on adoption is limited, it does suggest that these sernces are often fragmented and poorly coordinated and that they frequently focus on the prenatal period but overlook the young woman's need for support and assistance following delivery. Goal 3: Promote Positive Social, Economic, Health, and Developmental Outcomesfor Adolescent Parents and Their Chiidrer: Childbearing among school-age adolescents will never be entirely eliminated. The birth rate for teenagers and the number of children born to young mothers have declined over the past decade and a half, and they are projected to continue to decline into the 1990s. Aggressive and committed prevention approaches may farther reduce adolescent child- bear~g. Even so, some teenagers experience unplanned pregnancies and become parents. Many of those who do are at serious risk of health and nutritional deficiencies, single parenthood, unemployment, poverty, and long-term economic dependence. Their children wiD have a higher probability of physical, social, and cognitive problems and deficiencies. Although parenting teenagers represent a small proportion of the overall adolescent population, their problems and needs entail high public costs. Accordingly, a third important goal is to promote positive outcomes for adolescent parents and their children. Several strategies can poten- tia~y contribute to the achievement of this goal. Central to all of them is the recognition that teenage parents are not just young mothers: teenage fathers must also be a target for policies and programs, as must the families of pregnant and parenting adolescents. Promote Healthy Birth Outcomes and Support the Physical Health of Young Mothers and Their Babies Expectant mothers who receive early and regular prenatal care that is appropriate to their level of risk are signifi- cant~y more likely to have healthy birth outcomes than those who do

282 ADOLESCENT SEXUALITY; PREGNANCy AND CHILDBEARING not. Those who obtain regular preventive health care for themselves and their children are likely to develop more positive health behaviors and their children are more likely to avoid or overcome many of the most difficult child health problems. Although it is possible, given current knowledge and technology, to prevent or ameliorate many maternal and child health problems, many teenagers and their children do not receive essential health care seances. In some cases these services are not accessi- ble to them; in many cases they are available but underutilized. Informa- tion, outreach, and follow-up are essential aspects of maternal and child health services for adolescents. The panel recommends continuer support for the provision of appropriate health and nutrition services, including prenatal, labor, and delivery care for pregnant adolescents and regularanl emergency pediatric carefor the children of teenage mothers, through Medicaid; the Early and Periodic Screening, Diagnosis and Treatment Program; and other federal and state maternal and chill health programs. Bureaucratic barriers that prevent teenagers from receiving early, regular, and appropriate care for themselves arid their children should be mini- mizel. Several interventions can promote healthy birth outcomes arid can help support the physical health of young mothers and their babies. Prenatal, labor, and delivery care Early and regular prenatal care significantly reduces the likelihood of pregnancy complications, labor and delivery complications, and maternal morbidity. It also reduces the likelihood that young mothers will deliver premature and low b~rthweight babies. Although prenatal care services are widely available from public health departments, hospitals, freestanding clinics, school- basedclinics, youth service agencies, end private physicians, adolescents are less likely than older mothers to obtain early or any prenatal care. Because of their long-term health benefits, prenatal care sernces must be available aIld accessible to all pregnant adolescents. They should begin as early as possible in pregnancy, and they should continue through labor and delivery and dunug the immediate postpartum penod. There should be appropriate linkage between prenatal and delivery care providers so that relevant information about a patient's health status and health Stow are available at the the of deliver. Pregnant teenagers rely heavily on federal programs to pay for their prenatal, labor, and delivery care, including support from Medicaid, the

PRIORITIES FOR POLICIES AND PROGRAMS 283 Early and Periodic Screening, Diagnosis and Treatment Program, and other maternal and child health programs. Bureaucratic problems in- volved in adolescer~ts' applying for subsidized services and establishing their eligibility, especially Medicaid eligibility, have been shown to affect the timing of prenatal care for many pregnant teenagers and may even deter some from seeking any care at ah. Such barriers should be mini- mized. Program research suggests that two components of service delivery are essential to help pregnant teenagers receive adequate prenatal care beginning in the first trimester of pregnancy. These include pregnancy testing and counseling services as soon as pregnancy is suspected, and information and health education to inform teenagers of the importance of preventive health care and avoidance of health hazards (e.g., smoking) during pregnancy. In addition, the provision of health care services at or in proximity to the school has been shown to enhance school-age teenag- ers' access to and use of prenatal care. The introduction of comprehen- sive health clinics in many schools represents a positive step toward strengthening prenatal care services for pregnant students. In the limited evaluation studies that are available, these facilities have demonstrated their effectiveness in increasing the likelihood that pregnant teenagers wid initiate care in the first trimester and will be monitored regularly throughout their pregnancy, in accordance with standards set forth by the American College of Obstetricians and Gynecologists. Nevertheless, prenatal care, labor, and delivery services should continue to be available to teenagers in a variety of settings, since many high-risk expectant mothers are not enrolled in school. Nutrition services The dietary habits of many adolescents and low- income individuals are poor. During pregnancy and when breast- feeding, nutrition needs are especially critical, and many young mothers suffer from anemia and vitamin deficiencies. The problems of maloour- ishment include complications in pregnancy and childbirth and low birthweight. In young children, nutntional deficits can delay physical development, increase susceptibility to disease, and negatively affect learning. The Supplemental Food Program for Women, Infants and Children (WIC) provides iron-rich and protein-nch food supplements tO low-income pregnant women and mothers and children under age Eve. it has been shown tO reduce the incidence of problems associated

284 ADOLESCE.~JT SEXUALITY PREGNANCY AND CHILDBEARING with malnourishment. It has also been shown to serve as a means of recruiting hi~h-risk pregnant women into prenatal care. O cot ~ ~ Pediatric care Well-baby care, as well as emergency care, has been shown to improve the physical health of all children, especially those at serious risk of pennatal dysfunction. As with prenatal care, info' Elation and health education can help young mothers and fathers understand the importance of well-baby care and positive health behaviors for their children's long-term development and well-being. Pediatric care programs and well-baby clinics are available to teenage parents through public health departments, hospitals, freestanding com- munity clinics, and school-based clinics. These programs involve a van- ety of sennce delivery models, including clinic services, home nsits, and the integration of other necessary services, such as nutrition services, contraceptive seances, and education and career counseling. Most teen- age parents who seek publicly subsidized services rely on federal pro- grams to pay for those services, among them Medicaid, the Early and Penodic Screening, Diagnosis and Treatment Program, and to some extent other maternal and child health programs. There is some evidence that eligibility standards and application procedures in some states may discourage needy parents from seeking well-baby and emergency care for their children. These bureaucratic barriers should be minimized. Prevent Subsequer:t Untimely and Unintended Births An untimely and unintended birth tends to have seriously negative social and economic consequences for young mothers, young fathers, and their children. A second untimely an] uninten~eci birth is likely to compound the already complex and overwhelming problems. Many adolescents who give birth experience repeat pregnancies within two years. Although most adoles- cent parents report that they did not intend to become pregnant again SO quickly, most did not take effective steps to prevent conception. Contra- ceptive diligence requires a significant degree of commitment. Many teenage girls are easily dissuaded from regular contraceptive use by boyfriends, by problems in using their chosen method, or by informa- tion (often inaccurate) about possible negative side effects. Adolescents who have expenenced childbeanng are no different. Helping them to prevent subsequent untimely and unintended births requires that their family planning needs receive special attention and emphasis.

PRIORITIES FOR POLICIES AND PROGRAMS 285 Several interventions have the potential for preventing subsequent untimely and unintended births to adolescent parents. Contraceptive services The use of contraception reduces the proba- bility of pregnancy. Getting adolescent mothers and fathers to practice contraception regularly can substantially lower the likelihood of a repeat pregnancy an] birth. Several aspects of service delivery to this target population are important: aggressive outreach and follow-up to reach parenting teenagers as soon as possible after delivery, assistance in getting them to clinics, and close monitoring of their success or difficlity in using their chosen method; directive advice on contraceptive practice; easy access to convenient, low-cost (or no cost) contraceptive seances; and intensive irldindualized care. Low-key approaches to contraceptive use in several comprehensive pregnancy care programs have been shown to be insufficient. Leaming to contracept successfully is difficult for many adult women. For teenagers who lack experience, confidence in their social relationships, and the ability to plan ahead, it is even more difficult. For many parenting teenagers who cannot foresee other viable life options than motherhood, a forceful and consistent message about the risks of subsequent pregnancy and the importance of contraception are essential. While contraceptive services alone cannot control subse- quent fertility among teenage parents, they are a necessary first step. The panel concludes that contraceptive services should be available and accessi- ble to adolescent parents at 20w or no cost. Because of the special needs of this high- nsk population, sentence providers should strengthen: theirprograms by0J enhanc- ing their outreach efforts to encourage early use of contraceptive methods; (2) developing 2r'rensive individualized counseling and care techniques to encourage compliance; and (3) enhancing their follow-up procedures to track contraceptive use. Abortion services For those who experience repeat pregnancies and fee] unable to cope with the compounded difficulties of raising more than one child, abortion is an option for pregnancy resolution. Ensure the Economic Weli-being of the Teenage Family For teenage parents, especially those under age 18 and those without a high school diploma, who have not yet developed the ability to support themselves, economic well-being is a major concern. Adequate income support is a

286 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING necessary precondition to school completion and to promoting the health and well-being of young mothers and their children. Severe poverty increases the likelihood of poor health, inadequate nutrition, personal frustration, and early economic dependence. Ensuring the economic security of teenage families until they are able to become self-sufEc~ent is an essential strategy to achieving the larger goal of promoting positive outcomes for these young parents and their children and should involve partners, families, and the community. Two interventions are especially relevant. Child support enforcement Fathers should be involved in the Enan- cial support of their children. Teenage fathers, who may not have com- pleted school and who are employed only part-time or who are unem- ployed, are unlikely to be able to make a significant contnbution to the support of their children while they are still in their teens. For this reason, young fathers have not typically been actively pursued by the state for child support. However, there has been renewed interest In enforcing child support by fathers of children born to teenage mothers, both to provide additional financial assistance to young mothers and as a means to increase young men's sense of parental responsibility. Indeed, parents are obligated to provide support until their children reach age 18, and even if the father's current level of financial assistance is low, his contnbution may increase over time and have long-term positive effects on his children. There is little existing research or program experience to guide new polices in teds area. However, farther efforts shoed be made to encore the effects and effectiveness (short-term and long-term) of child support enforcement among teenage fathers. As a first step, young men should be educated about their child support obligations. In addition, efforts should be made to link child support to education and work require- ments in the fonn of (~) registration tenth the state employment service and (2) participation ~ job training and job search activities as well as work opportunities. At a tUne when an increasing number of states are adopting "workfare" programs for welfare mothers (including the mothers of very young children), it is appropriate to consider similar public jobs programs for the fathers of young children who camlot otherwise fed work and pronde support for their families. The families of adolescent parents should also be encouraged to as- sume responsibility for the support and obligations of their minor chil

PRIORITIES FOR POLICIES AND PROGRAMS 287 dren, including the children of teenagers under 18. Research suggests that adolescent mothers, especially school-age gratis, who remain in their parents' home and receive support and assistance from their families, fare better In the short term than those who establish independent house- holds. In turn, the children of young mothers benefit from this support and assistance. Program experience in this area is extremely limited, although several states, most notably Wisconsin, have recently enacted statutes requiring grandparent support for the children of adolescent mothers. While it can be assumed that enforcing grandparents' liability win increase the financial resources to teenage parents and their children, there are no data to show whether such provisions will serve the larger purpose of strengthening family bonds and stimulating emotionally supportive parental involvement, or wig have less desirable effects. Aid to Families With Dependent Children Public assistance for adolescent mothers and their children represents an important source of economic secunty when husbands or partners and families are unable to meet the necessary level of financial support. The availability of AFDC and related food stamp and Medicaid benefits has raised controversy over the extent to which it encourages young women to become parents before they are able to become economically self-sufficient. Although there is no evidence that AFDC benefits encourage young women to become sexually active or to become pregnant, there is some evidence that they may influence decisions concerning living arrangements of pregnant and parenting teenagers. The 1984 Deficit Reduction Act amendments to the Somal Security Act established that teenage parents eligible for AFDC and living with their parents must be included In a household grant. Minor mothers living apart from their families, how- ever, are eligible to receive benefits on their OWD . This regulation may constitute an incentive for a teenage mother to establish independent Wing arrangements, thereby ~r~dermining her fan3ily's obligation and ability to provide financial and emotional support. To the extent that 1984 legislative changes governing AFDC eligibility deny income and Medicaid benefits to young mothers and their children if they remain in the parental home, these provisions should be carefully reviewed. Trre- spective of federal action governing AFDC eligibility, the states should explore policy options to allow adolescent parents under age 18 to remain in their families of origin whenever possible until they have completed high school (or the equivalents, until they are able to become

288 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING economically self-sufficier~t, or both. There is little research evidence to support policies in this area. One possibility, however, is to link the receipt of AFDC benefits by teenage mothers to remaining in their parents' home, except under conditions that pose a physical or emotional hazard to the adolescent or her baby. Enhance Life OptionsforAdolescent Parents Efforts to improve mater- nal and child health outcomes, to improve developmental outcomes among the children of adolescent parents, and to prevent subsequent pregnancy may have little positive eEect until teenagers can be persuaded to "invest in their own Futures." Both the motivation and the means are essential to overcoming the likely negative consequences of early child- beanug. Although many teenage mothers (and fathers) report aspira- tions that are very similar to those of their peers who delay childbearing a nice home, a good job, and a Toning spouse they frequently have ~if~cuity ennsion~g in concrete terms how to make their dreams attainable. Therefore, a fourth important strategy for im- pronng social, economic, and health outcomes for adolescent parents and their children is to enhance their life opportunities. Several approaches appear to be especially promising: Life management training Life planning assistance is important to help teenage parents, both mate and female, establish education, career, and family formation goals for themselves and to identifier pathways to achieving these goals that take account of their parenting responsibili- ties. Similarly, life skills training to help them learn how to manage their everyday lives independently are important to success in pursuing their chosen work and family goals. Teenage parents need to have realistic dress Is of what they can be, in addition to being a parent, and an understanding of how to ~ those dreams, one step at a time. Re- search conclusively demonstrating the impact of life management train- ing on the economic self-sufflaency, marital stability, and parenting skills of teenage parents is not available, and efforts to develop and test mode} programs of this type are needed. Educations support and remediation The detrimental effect of early childbeanng on educational attainment has been clearly demonstrated. Most teenagers who become mothers before they graduate do not finish high school. Similarly, many adolescent fathers who assume parenting

PRIORITIES FOR POLICIES AND PROGRAMS 289 responsibiiines often find it difficult to complete their education. The relationship between school performance, school attendance, and ado- lescent childbearing is complex. Many teenagers who become parents are at risk of dropping out of high school or have left school before they became pregnant. Parenthood for these young people may represerlt a more positive immediate experience than education. For those who have consistently failed ~ the classroom, there is understandably little incen- tive to return. Yet adolescent parents must be made to recognize that Hmshing school is essential to fulfilling their other aspirations for home, family, and work. In some cases, regular classrooms and mainstream educational programs may not be appropriate. Many of these young people need intensive remedial education and self-paced instruction to be successful. Alternative school programs, including high school equiva- lencyr courses, represent one option; others may include home instruc- tion or TV instruction to meet the special needs of these high-nsk students. Accordingly, the panel urges that a broad array of special education programs and servicesforpregrzantandparenting teenagers be developed and implemented to assist these young people in completing their education. Employment programs Regardless of the availability of child sup- port, older pregnant and parenting teenagers (18- and 19-year-olds) need employment services that provide job training and assist In job place- ment. Those under age 18 need services that emphasize the importance of completing high school, while eIlhaIlcing their later employability and transition from school to work. Younger teenagers may benefit from information concerning career alternatives and job requirements, job readiness and job search skids, and temporary or part-time work experience. As with employment programs that are aimed at preven- tion, those sensing pregnant and parenting teenagers need to take into account the related service needs of these young people, including child care, transportation, counseling, etc., which can significantly affect their participation and outcomes. Many existing youth employment programs have excluded teenage parents because of their special needs. In this regard, the problems of adolescent fathers require special attention. Employment opportunities are so inadequate and earnings are so low for many young men, especially m~nonties, who have been reared in poverty and who lack education, job training, and work expenence,

290 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING that they are not able to participate in their childrer~'s support. To encourage teenage fathers to become economically responsible for their offspring and to form self-sufficient two-parent fa:Tulies requires that opportunities be available to them to enhance their employability and earnings. The panel concludes that efforts should be continued to strengthen and expar2d age-appropnate employment programs for pregnant girls and teenage parents, both male andiemale. Child care services Research confirms that young parents who have access to and use child care in their families or In their community are more likely to finish high school and to enter thejob market. Studies also suggest that some child care services can positively affect the parent-child relationship-for both mothers and fathers. In general, there is a short- age of organized child care services, especially infant care, and sernces that are geared to the special needs of adolescent parents are few. For many teenage parents who have working parents themselves, family care is unavailable. For teenagers to appropnate~y use child care, these serv- ices must be conveniently located; they must have hours of operation that are compatible with school schedules; they must be affordable; and they must provide emotional support and guidance to young parents who may not Filly understand their roles and responsibilities. Some schools and employment training programs are experimenting with on- site child care. Such facilities have the potential for responding to the special needs of adolescents. Neighborhood-based family care and center care can similarly provide the necessary services to help teenagers remair in school or enter the job market and enhance their parenting behavior. The pane] recommends that support be rovidedfor the development, impZe- mentation, and evaluation of mode] child care programs that are targeted to the needs of teenage parents. Schools and other community organizations should place high priority on establishing and maintaining these servicesfor the children of adolescents. Comprehensive care programs The expenence of comprehensive care programs for pregnant and parenting teenagers has been mixed. While these programs have frequently produced positive short-term outcomes In a number of areas-education, work, parenting, health

PRIORITIES FOR POLICIES AND PROGRAMS 291 behavior, and so on there is no evidence of their having significant long-term positive effects. Indeed, the special needs of teenage parents are many, and coordination of supports and services to respond to those needs is difficult without a centralized case management capability. In addition, because most teenage parents have expenenced frustration and failure, they often require intensive, individualized attention, encour- agement, and assistance to overcome the complex problems they face. Comprehensive care programs have sought to do this by providing or brokering a mix of services appropriate to the special needs and circum- stances of indiv3 duel teenagers. These programs are expensive, and eval- uations have not yielded much insight concerning the value or benefit of the van ous program components, either singly or ~ combination. In the absence of more complete understanding of how particular aspects and components of comprehensive care programs work and the extent of their potential benefit to clients beyond the period of participation, large new expenditures for interventions of this type are not warranted. Nevertheless, we recognize that many teenage parents need a variety of supports and services that are riot available unthm their families. Simply putting these services in place in the community will not ensure that teenagers wiD benefit Tom them. Many high-nsk adolescent par- ents require intensive individualized attention and care in order to have their basic needs met, to help them locate and take advantage of available public aide private services, and to help them fillEll their aspirations. The pane] urges that public and voluntary community agencies explore ways of developing and evaluating case management capabilities to help adolescent parents obtain necessary supports and services. Promote the Social, Emotional, and Intellectual Development of the Children of Adolescent Parents The children of adolescent parents are espec~aDy vulnerable to behavior disorders, problems In school adjustment, lower mtedigence and achievement scores, and retention ~ grade. These diffi- culi~es are only partly the Sect reset of their mothers' young age =d lack of schooling. They are also affected by poverty, poor nutrition, low birthweight, andlivingm a s3mgI-parent household, many of which are closely associated with adolescent childbearing. Special supports and services are needed by many adolescent parents to prevent or overcome these difficulties and to promote their children's healthy somal, emo- tional, and cognitive development.

292 ADOLESCEAi-T SEXUALITY PREGNANCy AND CHILDBEARING One intervention in particular has the potential for ~rthenng this strategy. Parenting education Parenting education has been shown to im- prove young parents' knowledge of children's patterns of growth and development and appropriate child care, as wed as to help them learn techniques for stimulating infant response and development. Such pro- grams should be available to teenage parents, both male and female, and should be sensitive, not only to the developmental requirements of infants and toddlers, but to the developmental matunty and capabilities of the young parents. Teenagers who have not grown up ir1 supportive, ennch~g families may have little positive basis for modeling their own parenting behavior. The pane] urges that parenting education for teenage parents, especially those from severely disadvantaged backgrounds, receive special attention and emphasis. Schools and other community organizations should place high pnority on the development, implementation, and evaluation of these programs. CONCLUSION As we stated at the beg~namg of this chapter, the panel's framework for policy and program development is organized around three funda- mentai goals: the East is reduction of adolescent pregnancy; the second is provision of alternatives tO adolescent childbeanng and parenting; the third is promotion of positive outcomes for adolescent parents and their children. For each of these goals, several strategies and specific interven- tion approaches have been presented. It is important tO recognize that none of these interventions alone can solve the complex problems of adolescent pregnancy and childbeanug; nor can any single strategy ad- dress the special needs and characteristics of aD youth at risk of untimely and unintended pregnancy and birth. In presenting several strategies for achieving each of these goals, we have med tO take account of the diversity of the adolescent population of their different values, differ- ent social, economic, and CU]tUI~ backgrounds, different ages and stages of development, different communities and support systems, and differ- ent dreams for the fixture. The strategies toward each goal are interde- pendent. They are not mutually exclusive. Providing young people Ninth

PRIORITIES FOR POLICIES AND PROGRAMS 293 the ability to avoid pregnancy and childbearing or to cope with early unplanned parenthood and helping them develop the will and the will- ingness to do so are both important. Neither alone is sufficient. As we have stressed throughout this report, there are no easy answers or quick fixes. Those seeking simple new solutions will 6~d there is really very little that is new or simple. Any efforts to alleviate the problems of adolescent pregnancy and childbeanug will ultimately re- quire a sustained, coordinated commitment by policy makers, service providers, parents, and teenagers themselves. Everyone can be touched by the problems; everyone can indeed, must contribute tO the solu tiOIl. The problems of adolescent pregnancy and childbearing are solidly rooted in many of the forces and pnnc~ples that shape our sonety- ~ndiv~dualism, family autonomy, and free enterpnse. As a nation, we have no coherent policy in this area because we have no unitary view of these issues or approach to addressing them, and because we have been unable to deSIle an appropriate public role ~ decisions regarding the initiation of sexual activity, contraception, pregnancy resolution, and parenting. This ambiguity and disagreement will not be easily resolved. Nor should it. We are a diverse society of individuals, families, and communities with diffenug values, traditions, and cultures. In shoe, the panel believes that a number of actions should continue to be taken sunultaneously. They must involve government at all levels as well as the private sector, including business and labor, religious groups, special interests, and the media. Some represent immediate steps that can yield shon-term results; others wiD require a longer-ter~ investment of time and resources. This report represents one step in a continuing, incremental process. As a scientific group, we have staved to clarify the issues, sharpen awareness of crucial decision points, and bring knowledge to bear on the trade-offs and complementani~es among different political and ideolog~- cal positions. Perhaps our most important contnbution is to ~nfo~u the continuing debate concerning this salient and often divisive issue of the limits of scenic understanding.

Next: References »
Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing Get This Book
×
Buy Paperback | $100.00
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

More than 1 million teenage girls in the United States become pregnant each year; nearly half give birth. Why do these young people, who are hardly more than children themselves, become parents? This volume reviews in detail the trends in and consequences of teenage sexual behavior and offers thoughtful insights on the issues of sexual initiation, contraception, pregnancy, abortion, adoption, and the well-being of adolescent families. It provides a systematic assessment of the impact of various programmatic approaches, both preventive and ameliorative, in light of the growing scientific understanding of the topic.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!