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4
The Dilemma of Teenage Parenthood
Teenage pregnancy and childbearing have for some years been re-
garded as difficult and grave problems for the United States. Although
policies and programs have been developed to reduce the incidence of
children having children, their combined impact has been minimal, and
the rates of adolescent pregnancy and childbearing remain high. As the
Center for Population Options noted in 198S, a cycle of poverty often
begins with an unintended adolescent pregnancy. Teenage pregnancies
do not occur in a vacuum. Too often they are the product of economic
disadvantage and inadequate educational systems, of poor housing, fam-
ily instability, and the emotional deprivation associated with it. Because
the children of teenage mothers have an even slimmer chance of escaping
these conditions, they, too, may become adolescent parents.
The reality of almost 1 million teenage pregnancies a year demon-
strates that this country's social and economic systems are failing a
substantial proportion of our young citizens and, in doing so, are helping
to perpetuate and enlarge the number of poor and badly educated men
and women.
This chapter outlines the extent of the dilemma and examines how
the United States compares with other industrialized countries in levels
of teenage pregnancy, births, and abortions. It discusses the economic
and social costs of adolescent childbearing on young parents and their
children and on the nation. Some promising new intervention programs
69
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SCIENCE AND BABIES
to prevent teenage pregnancy are reviewed, and suggestions for research
on additional solutions are made. Biomedical research on the onset of
puberty may provide some solutions, but the majority of the answers
must come from the social and behavioral sciences.
THE SCOPE: OF THE PROBLEM
In the United States each year approximately 1 out of every 10 young
women between the ages of 15 and 19 becomes pregnant, a ratio that has
changed little since 1973. According to the National Center for Health
Statistics, in 1985 16.6 of every 1,000 girls aged 14 and younger and
109.8 of every 1,000 teenagers between ages 15 and 19 became pregnant.
The 1986 Alan Guttmacher Institute study of teenage pregnancy in
industrialized countries demonstrates that the rates of adolescent preg-
nancy, childbearing, and abortion in the United States outstrip those of
other similarly developed nations, including Canada, England and Wales,
Sweden, the Netherlands, and France. In England and Wales the preg-
nancy rate among girls 14 and younger is 3 per 1,000; for 19 year olds,
it is 86 per 1,000.
Although the pregnancy rate for black adolescents in the United
States is considerably higher than the rate for white teens, this factor is
not significant enough to explain the disparity between the United States
and other industrialized nations. The pregnancy rate for U.S. white
adolescents alone is twice as high as the rate for teenage pregnancies in
Canada, the country closest to the United States in its proportion of teen
pregnancies.
This disparity is all the more puzzling when viewer! against the fact
that, according to the Guttmacher study, U.S. teenagers are no more
sexually active than their peers in similar countries. The frequency of
abortion and pregnancy in the United States cannot be accounted for by
a greater frequency of sexual activity.
Despite efforts at the federal and state levels and by many private
agencies to reduce the number of pregnancies among the young, the
percentage of U.S. teenagers who become pregnant has not changed much
in the past 16 years. Researchers at the Guttmacher Institute estimate that
in 1987 there were more than 1 million pregnancies among adolescents
and most of them were unintended. About half the adolescents who
become pregnant give birth and about half have abortions. The number
of spontaneous abortions, or miscarriages, is not known, but if it were
possible to record such occurrences, Dr. James Trussell, of Princeton
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TEENAGE PARENTHOOD
71
University, believes the total number of teenage pregnancies would rise
by 10 to 15 percent.
PRECURSORS OF TEENAGE PREGNANCY
Lack of Contraceptive Use
Why does the United States differ so markedly in its levels of
adolescent pregnancy, childbirth, and abortion? In reviewing data on
the United States, Sweden, Canada, England and Wales, France, and the
Netherlands, Dr. Trussell declares:
The main reason for higher pregnancy rates in the United States is that
American adolescents are less likely to use contraceptives regularly, or use
them less effectively, than those from the other five countnes. Further,
among contraceptive users, smaller proportions of U.S. teenagers rely on the
most effective methods, particularly the pill.
Contraceptive services and supplies are widely available and either
inexpensive or free in the Netherlands, England and Wales, and Sweden.
In France contraceptive services are less accessible, but the situation is im-
proving. In Canada contraceptive services and information for teenagers
are not always readily available, and nonprescription contraceptives are
not covered by the national medical insurance system. In the United
States a network of clinics makes services available to adolescents in
most communities, but because many of the clinics were developed to
serve the poor, they have a negative image and are avoided by many
teenagers who consider them "welfare" clinics.
For teens who do not use clinic services, the alternative is to seek
contraceptive care from a private physician. Some 30 percent of sexually
active teens use private physicians for contraceptive care. But the costs
of doctor visits and contraceptive supplies are often beyond the reach of
many adolescents. Moreover, a substantial percentage of physicians who
provide reproductive health services will not reduce their fees or accept
Medicaid, making them largely inaccessible to low-income women. In
general, Medicaid does not cover poor single people who do not have
children or are not pregnant, poor married couples, and people whose
incomes are just above the poverty levels used as Medicaid standards.
Many American teens do not have a family doctor, and many fear that
a private doctor would be unwilling to provide contraceptive services to a
minor or would require parental permission before doing so. Surveys of
physicians show this perception to be generally accurate for pediatricians
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SCIENCE AND BABIES
and family doctors. Few obstetricians and gynecologists, on the other
hand, would refuse contraceptive care for teenagers.
Failure to use contraceptives is only part of the teenage pregnancy
problem. Other forces have an important impact on whether adolescents
become sexually active, whether they use contraceptives or become preg-
nant, and whether they terminate their pregnancies or bear a child. Each
teenager is influenced by the circumstances of that particular time and
environment and by her view of herself and her world.
Early Onset of Puberty and Delayed Marriage
One factor that increases the probability of a teenager becoming
sexually active and pregnant is the fact that in industrialized countries
young people reach puberty earlier and marry later, a trend that began
around the 1820s. Instead of the two- or three-year time span between
menarche and marriage that was usual in earlier generations, today a
girl may have her first menstrual period at age 10, generally does not
complete high school until she is 18, and may not marry until she is in her
20s. As Dr. Daniel Federman of the Harvard Medical School has noted:
"It is this window of time within which the events we are discussing
occur and for which social policy needs to be considered."
Dr. Malcolm Potts adds that "Teenage pregnancy is the kind of cruel
paradox that biology and modern living play on us: in the very century
when the duration of education has risen, the age of puberty has fallen
dramatically."
According to Dr. Federman, the persons at greatest risk of pregnancy
during this long interval between menarche and marriage are girls 15 and
younger who come from poor, probably single-parent families and who
are just beginning sexual activity. When adolescent girls begin to have
intercourse, the frequency is generally unpredictable. A girl may not be
willing and intercourse may be forced on her. Some observers feel that the
ability to think logically may not be sufficiently developed at such an early
age and that girls may not recognize that they are making a choice and
that their choice may lead to pregnancy. However, the National Research
Council Panel on Adolescent Pregnancy and Childbearing pointed out
that in other countries even very young sexually active teenagers can
learn to use contraceptives effectively.
To become sexually active, in essence, means the teenager makes
a decision, Dr. Federman says. In some studies of adolescents, having
sex has been linked with other risk-taking behaviors, such as smoking,
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TEENAGE PARENTHOOD
73
drinking, or using illicit drugs, which some teens associate with becoming
an adult. If they adopt one behavior, they are likely to adopt the others.
Dr. Federman sees a difference, however. He believes that for adolescents
the drive to behave reproductively can be more powerful than the drive
to smoke or drink or take illicit drugs. "From my point of view, for
a teenager the issue of having sex is a 'when' question, not so often a
'whether' question, as are the other decisions," Dr. Federman says.
Poverty
Poverty appears to play a major role in adolescent pregnancies. Many
of the factors believed to lead to early sexual experience and pregnancy
are characteristic of poverty: low-quality education, a negative perception
of the future, limited employment opportunities, fatherless families, and
feelings of helplessness and alienation. Children who grow up with few
or no financial or familial resources may not realize how their dreams
for education, marriage and a family, or a job can be hindered by early
childbearing. Or they may feel they have no choices.
With inadequate basic skills, poor employment prospects, and few
role models who have managed to break out of poverty, it is not surprising
that many teenagers see no reason to postpone pregnancy.
Lack of Educational Goals
A strong association exists between early sexual experience an
low intellectual ability, academic achievement, and a lack of educational
goals. Researchers have found that many young women are below grade
level in school at the time they become pregnant; others had already
dropped out of school. Girls who are interested in getting an education,
who score high on intelligence tests, and who are doing well in school are
less likely to become sexually active at a young age. These findings may
partially reflect individual ambition, regardless of family background, but
much of it quite probably reflects cultural or family aspirations.
Religious Involvement
Studies show that adolescent girls are more likely to be sexually
active if they are not regular church goers and if they state that religion is
not very important to them. More important than any particular religious
affiliation, these studies found, is the tendency to be devout and concerned
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SCIENCE AND BABIES
about religious teachings and customs. Some observers postulate that
religious teenagers may be more traditional and less inclined toward
risk taking in other aspects of their behavior. In addition, the important
family and social contacts in their lives may be supportive of traditional
behavior.
Family Relationships
The National Research Council (NRC) panel discovered that, in
general, the effect of parental relationships and communication between
parent and child on teenage sexual activity may be small. Studies reveal
that the parents' role in sex education is relatively minor. The panel
reported:
First, in many cases, less parent-child communication takes place than
is commonly assumed; second, such communication, whether to provide
information or to prescribe behavior, may not be fully heard by the child;
and third, communication about sexual behavior frequently does not occur
. ~ . . . . . .
until atter ~n~t~at~on of sexual activity.
Similarly, studies of the effect of parental supervision on teenage
sexual experiences have demonstrated conflicting findings. One study
showed that more supervision was associated with less sexual activ-
ity; other studies found no relationship between more supervision and
adolescent sexual behavior.
Some aspects of families do have an impact. If a mother's first
sexual and childbearing experiences occurred in her teens, it is probable
her daughter's will as well. Girls whose families are not intact or who
come from a home headed by a woman are more apt to have sexual
experiences at an early age. Researchers also found that in large families
the oldest child probably becomes sexually active by the time younger
siblings reach adolescence, thereby providing a role model for such
behavior.
When Washington Post investigative reporter Leon Dash researched
his series on teenage pregnancy, he interviewed the members of six
families begun by an adolescent pregnancy. The families were charac-
terized not only by poverty, instability, and closely spaced births but
also by a lack of affection between parents and between parents and
children. Although they cannot possibly represent all families started by
a teen pregnancy, their lives and words provided a glimpse of some of
the reasons adolescents become pregnant. One of the teenagers Dash
interviewed told him:
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TEENAGE PARENTHOOD
When girls get pregnant, it's either because they want something to hold on
to that they can call their own or because of the circumstances at home.
Because their mother doesn't pamper them the way they want to be pampered
or they really don't have ar~yone to go to or talk to or call their own. Some
of them do it because they resent their parents.
Peer Pressure
75
The influence of a teenager's peers is often cited by observers as the
single most important factor affecting the initiation of sex among young
men and women. But the NRC panel cautioned that peer influence may
be overrated, particularly among white males and blacks of both sexes.
Teenage behavior is affected as much by what they think their friends
believe and do as by what actually occurs.
Some studies indicate that white girls may be most vulnerable to
peer influences, particularly the attitudes of their closest male friends,
and that peer pressure among black boys and girls seems to be relatively
minor. On the other hand, after 17 months of interviewing and closely
observing black adolescents and their families, Dash found that peer
pressures definitely helped to encourage teens to become pregnant. Dash
lived among and studied adolescents in the Washington Highlands section
of Washington, D.C. Among those families, who originally were from
the rural south, being sexually active, getting pregnant, and having a
baby were important markers of attractiveness and of becoming an adult.
Girls who still were virgins in their mid-teens were ridiculed and teased
by friends and siblings. Dash wrote:
In time it became clear that for many girls in the poverty-stricken community
of Washington Highlands, a baby is a tangible achievement in an otherwise
dreary and empty future. It is one way of announcing: I am a woman.
For many boys in Washington Highlands the birth of a baby represents an
identical rite of passage. The boy is saying: I am a man.
WHAT DETERMINES CONTRACEPTIVE USE?
The National Survey of Family Growth found that fewer than half
the sexually active adolescent girls who responded to the 1982 survey
reported using a contraceptive the first time they had intercourse. Other
research shows similar low rates of contraceptive use. In the 1976
National Survey of Young Women, 58 percent of young unmarried women
who did not use a contraceptive method said they thought they could not
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SCIENCE AND BABIES
conceive. Of the remainder, one of five said they had not expected to
have intercourse. When intercourse is still a new experience, Dr. lames
Trussell says, not anticipating it is an even bigger factor in adolescents'
failure to use contraceptives. In a 1979 study of the reasons sexually
active teens did not use contraceptives, 87 percent of the young women
surveyed said they did not expect to have sex.
Age
Age is an important factor in whether or not a girl is protected by a
contraceptive when she first begins to have intercourse. It is also a factor
in the type of method used. The older a girl is, the likelier she is to use
a medical method, most often the pill. Among boys, age appears to have
little effect on whether or not they use a contraceptive the first time they
have intercourse.
Educational Goals
Besides helping delay sexual behavior, educational aspirations affect
contraceptive decisions. Girls with clear educational goals who are doing
well in school are more likely to use contraception. Similarly, the adoles-
cent offspring of well-educated parents are more apt to use contraceptives
consistently. Black girls with clear educational goals are even more likely
than white girls or other black teenagers to use effective birth control.
Sex Education
Adults commonly assume that, if young people know how their
bodies work and know about pregnancy and contraception, they will be
more likely to seek family planning services and to use contraceptives
effectively. Researchers confimn this relationship, and apparently most
teens today know that a girl can become pregnant if she has intercourse.
But other studies as well as letters to teenage-advice columnists in the
newspapers make it clear that many teens, even those aged 17 and 18,
believe they cannot become pregnant the first time they have sex or if
they have sex only occasionally. Researchers questioned girls about their
level of sexual knowledge and found that many didn't know enough
to use contraception effectively. "The level and accuracy of knowledge
among teenage girls who are sexually experienced and those who are not
differ very little," the NRC report concluded.
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TEENAGE PARENTHOOD
a''\
5~
by, ,~
A baby is
A LIFETIME
COMMITMENT
Are you ready for this kind of obligation?
As a pregnant teen, your priorities must change.
77
This advertisement is one of a series designed by college students and aimed at alerting teenagers
to the consequences of pregnancy. Credit: Margaret Wehmeyer, University of Missouri at
Columbia
The NRC study also found that despite what many adolescents have
been taught they believe they are not at risk because they are so young.
Others, girls who have avoided pregnancy successfully without birth
control, believe they are immune and don't need contraceptives.
What is needed is a more thorough understanding of the connection
between what adolescents know and how they behave. Douglas Kirby, in
a 1989 evaluation of sex education programs and their effect on students,
found that while such programs could be quite effective in increasing
knowledge of conception and contraception, they apparently had little
real influence on sexual behavior and contraceptive use.
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SCIENCE AND BABIES
For his series on teenage pregnancy, Dash interviewed adolescent
parents in six families plus their mothers and other adult relatives who
had become parents as teenagers. He reported that he "did not find a
single instance in which procreation had been accidental on the part of
both sexual partners. While there was some profession of ignorance
about birth control among adults 40 years old and older, not one of
the adolescents that I met and interviewed had been ignorant about
contraception before becoming pregnant."
Although the sex education courses the teenagers had received varied
in quality and thoroughness, all of the adolescents Dash interviewed
were aware of birth control methods, particularly withdrawal, condoms,
and the pill. They expressed a generally negative attitude toward oral
contraceptives. They told Dash stories of bad things the pill could do to
a woman. Whether they truly believed these tales or whether they simply
did not like to use birth control is not clear. When a girl decided she
wanted a baby, she would talk her boyfriend out of using condoms or
withdrawal. Their statements corroborate research reports that substantial
percentages of white and black adolescents fear the real or perceived side
effects of birth control.
Acceptance of One's Sexual Behavior
Strongly connected with the competent use of contraceptives is the
adolescent girl's acknowledgment, to herself and others, that she is sex-
ually active. A low level of guilt and a positive attitude toward contra-
ception also are linked with effective contraceptive use.
Stage of Development
Girls with good self-esteem who view themselves as having a cer-
tain amount of control over their lives are more apt to use contraceptives
effectively. Girls who believe females should be dependent on males and
who are inclined to be passive generally do not practice consistent contra-
ception. Poor contraceptive use also is characteristic of girls who are risk
takers, who find it difficult to plan ahead, or who are impulsive. These
traits are also associated with boys who are poor users of contraceptives.
CONSEQUENCES OF EARLY CHILDBEARING
Knowledge of the consequences of teenage childbearing has grown
as the high rate of teen pregnancy has become a fact of life in the United
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TEENAGE PARENTHOOD
79
States. Research findings strongly indicate that becoming a parent while
an adolescent can have a negative impact on the lives of young mothers
as well as on their children. The youthfulness of the mother affects her
own economic, physical, and social status and that of her child. Although
she may eventually improve her own life, her children may not be able
to overcome the handicaps of being born to a adolescent mother.
Health Risks for Infant and Mother
Pregnant teenagers suffer more complications, miscarriages, and still-
births than do adult women, and for girls under age 15 these dangers are
intensified. Pregnant adolescents are also at greater risk of such compli-
cations as toxemia, anemia, prolonged labor, and premature labor.
Dr. Federman notes that this increased risk of complications origi-
nally was thought to be due in part to the reproductive immaturity of the
very young teenager, but physical immaturity is no longer viewed as a
principal factor. He says:
If good prenatal care is given and the concerns that are appropriate for
the pregnant adult woman, such as nutrition, control of anemia, control of
blood pressure, and finding gestational diabetes, are extended to the teenage
mother, then the medical outcomes of adolescent pregnancies are very close
to the medical outcomes of married, older women in the same society.
Because nutrition directly affects the health of mother and child,
babies born to teenagers, particularly poor teenagers, may be in greater
danger of long-term health and developmental problems. Adolescents
often have poor eating habits and these are magnified among low-income
teens. Young women often begin their pregnancies with poor health
habits, and they either do not know enough or cannot afford to alter their
life-styles in order to produce a healthy infant. Prenatal care is especially
important for pregnant adolescents, but many either do not seek care
until late in their pregnancies or receive none at all. As a result, their
newborns suffer disproportionately from prematurity, low birthweight,
and other conditions that require extensive and expensive hospital
care. Many of these premature infants suffer deficits that will persist
throughout their lives.
About 40 percent of all teenage pregnancies are terminated by abor-
tion. In contrast to the risks associated with early childbearing, complica-
tions from abortion occur less frequently among adolescents than among
adult women, regardless of when the abortion is performed, although the
earlier it is done the safer it is.
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85
On the negative side, sex education courses tend to be short fewer
than 10 hours and to concentrate on the physiology of sex. Not all
students take the courses. In the elementary and junior high grades, only
a small number of these classes discuss contraceptive methods. Programs
in senior high school are broader, and three-fourths of them cover family
planning, contraceptive methods, and abortion.
The obstacles to sex education are many. The Alan Guttmacher
Institute surveyed secondary public school teachers who were entrusted
with sex education courses. When asked about what they regarded as ob-
stacles to teaching the subject, they mentioned the difficulty of changing
students' ideas about sex and pregnancy, school boards with Victorian
attitudes, lack of support from department heads, inadequate funding, and
weak support from parents and the community, often because adults are
not well informed about sexual matters.
A variety of private community-based groups, such as the YWCA,
churches, the Scouts, and the Salvation Army, also sponsor sex education
courses.
One of the more successful privately funded programs was a coop-
erative effort between the Johns Hopkins University School of Medicine
and the Baltimore City Department of Education. Designed to prevent
pregnancy among urban teenagers, the Self Center program served a se-
nior high school and a junior high school that had a combined enrollment
of 1,700. Many of the students were drawn from an inner-city neighbor-
hood that contained low-cost and public housing; base-line questionnaires
revealed a high level of sexual activity among the students. The program
included classroom presentations; educational and counseling services
provided in the schools; and educational, counseling, and medical ser-
vices in a nearby storefront clinic open only to students from the two
schools. A full-time social worker and nurse practitioner were available
in each school and after school at the clinic. The project was unusual in
that it combined services and research and used two other city schools as
controls for evaluating the program.
Over a period of 3 school years, the Self Center project achieved
many of its goals. It markedly improved the level of student knowledge
of contraception and pregnancy risk, it significantly increased the use of
clinics and of contraceptive methods among teenagers already sexually
active, and it was able to draw males into its program.
Of particular interest were two results: (1) students exposed to the
project for all 3 years postponed their first intercourse experience for an
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SCIENCE AND BABIES
average of 7 months and (2) contraceptive use increased among all age
groups attending Self Center programs, particularly among students who
participated for 3 years. The active use of the storefront clinic and the
interest in contraception were underscored when the pregnancy rates for
the Self Center schools were compared with those of the two control
schools. After 28 months, pregnancies in the control schools increased
by 58 percent; in the Self Center schools, pregnancies dropped by 30
percent. The Johns Hopkins researchers reported:
While the changes in the age at first intercourse are not large, they are
substantial enough- in the direction of delay to refute charges that access
to such services as those provided by the program encourages early sexual
activity. The program's ability to effect any further changes may well have
been limited by the brevity of the project and the age of the students when
they were first reached.
The average expense for this comprehensive program was $122 per
student; the class lectures cost $5.56 per presentation per student; students
who used all the available services cost the program about $546 each.
The Self Center was an experimental program that ran from 1981
to 1984; although it no longer exists, some Baltimore schools now have
school-based clinics. The clinics do not provide contraceptives, but they
do refer students to local family planning centers.
The evaluation component of the Self Center program clearly demon-
strated the effect of a comprehensive pregnancy prevention program on
behavior. There is considerable anxiety among some segments of U.S.
society that such programs, or their components, might encourage earlier
sexual activity among adolescents. Others question the effectiveness of
family life/sex education programs in promoting responsible contracep-
tion among teenagers who already are sexually active.
The Johns Hopkins pregnancy prevention program provides
strong evidence that a comprehensive service can help adolescents to
postpone sexual activity and, if they are already sexually experienced,
to avoid pregnancy. In addition, this program demonstrates that such a
service does not lead to increased sexual activity.
Other studies also have found no link between sex education courses
and an increase in sexual activity. Although not as clear-cut in their
methodology as the Self Center program, these studies do indicate that
teenagers who were already sexually active are somewhat more apt to
use contraception and are less likely to become pregnant if they receive
some sex education.
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TEENAGE PARENTHOOD
87
According to Dr. Federrnan, the expense of preventing pregnancy is
dwarfed by the expense of experiencing it. The costs of sex education and
family life programs in particular are very low, dramatically so compared
with the amount of money needed to support a teenage mother and her
child for just one year. The NEC study panel on teenage pregnancy
found that the federal share of supporting a young family was $1S,710 in
1979 dollars. In contrast, the average per-student cost of classroom sex
education lectures in the state of Illinois came to $10 a year, similar to
the Baltimore cost.
The many families begun by teenage pregnancies annually cost the
public billions of dollars. As noted earlier in this chapter, the United
States in 1987 spent a total of $19.27 billion on these families. That figure
included both administrative costs and direct payments to providers of
AFDC, Medicaid, and food stamps. It did not include the costs of other
publicly supported services such as foster care, housing supplements, or
special education. A young woman who had a baby in 1987 and who
will receive welfare for about ~ years will cost the public approximately
$3S,700. Delaying such births markedly reduces such public outlays.
Efforts to Promote Chastity
Many people feel that the best way to reduce the number of teenage
pregnancies is to persuade adolescents not to have sexual intercourse.
Reasonable people agree that sexual intercourse in the younger teen
years benefits no one. The problem is determining which of the variables
influencing the onset of sexual behavior are open to change. The 1981 Ti-
tle XX Adolescent Family Life Act, which replaced earlier legislation for
adolescent health care and pregnancy prevention services, was designed
to put added emphasis on preventing early sexual intercourse.
The goal is a sensible one; the issue is how to achieve it. In the
1981 act less emphasis was given to birth control services. Instead, the
legislation sought to encourage premarital chastity by promoting strong
family values; it also encouraged the use of adoption as an alternative to
teenage childrearing.
In Risking the Future the NRC study panel reported that critics of
the family life program declare its approach is inappropriately moralistic.
The American Civil Liberties Union has brought suit against Title XX
on the basis that it represents a mixing of church and state.
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SCIENCE AND BABIES
Although some observers believe sex education programs that pro-
mote personal responsibility may help some adolescents postpone inter-
course, others feel that a large proportion of teenagers will continue to
become sexually active. Experienced researchers are not hopeful that
changes in sexual behavior will occur, especially in an environment in
which sex and sexiness are portrayed as important attributes in televi-
sion shows, movies, popular magazines, newspapers, and advertising.
Researchers at the Guttmacher Institute note:
American teenagers seem to have inherited the worst of all possible worlds
regarding their exposure to messages about sex: Movies, music, radio and
TV tell them that sex is romantic, exciting, titillating; premarital sex and
cohabitation are visible ways of life among the adults they see and hear
about....Yet, at the same time, young people get the message good girls
should say no. Almost nothing that they see or hear about sex informs them
about contraception or the importance of avoiding pregnancy.
The Guttmacher study concluded by noting that European countries
concentrate on preventing teen pregnancy and the United States concen-
trates on preventing teen sex, and that is why Europe is more successful
in reducing the number of adolescent pregnancies.
Improving Access to Contraception
For the sexually active teenager who wants to use birth control,
family planning services are available in almost every large community.
Providers include state and city public health departments, school-based
clinics, local hospitals, privately funded clinics, and private physicians.
Some provide a complete range of services, from information to obstetrics
and abortion; most centers refer patients wanting obstetrical, abortion, or
sterilization services to hospitals or doctors. In 1981 more than 5 million
teenagers were at risk of an unintended pregnancy. Of the 57 percent
who received family planning services that year, some 30 percent chose
public or private clinics and 21 percent went to private doctors.
Contraceptive services are available if adolescents make an effort to
find them; what is needed are ways to strengthen teenagers' motivation to
use them. The experience of European countries demonstrates that ado-
lescents can use contraceptives effectively. Unfortunately, in this country
several factors hinder contraceptive use, factors that are not a problem
in the United Kingdom, France, Sweden, or the Netherlands. They
are: a misunderstanding of the benefits and risks of oral contraceptives; a
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TEENAGE PARENTHOOD
89
highly visible, fundamental religiousness that is antisexual; racism; and
widespread, deep poverty.
Although religiousness and sexual conservatism do not always go
hand in hand, in the United States these two characteristics are often
closely linked. In the Guttmacher study of teenage pregnancy and child-
bearing in 37 nations, the researchers found that in this country a higher
proportion of the population attends religious services and believes God
is important in their lives. Fundamentalist groups in the United States,
which often hold very conservative views on sexual behavior, are both
extremely visible and vocal. The nature and intensity of religious feeling
in this country tend to introduce more emotion into public discussions
about providing reproductive health services to teens than is seen in other
countries.
In its prevalence and depth, the poverty that exists in this country is
almost unknown in the industrialized countries of Europe. In the United
States, one of every five children lives in poverty. Three out of every four
black children and one of every four white children experience poverty
by age 10; many of them are poor for at least four years. The 37-country
study found that in nations with more equitable distribution of family
income fewer adolescents become pregnant. Teenagers who have known
only poverty and see no hope of escaping it are not likely to feel they are
jeopardizing a rosy future by having a child.
With little chance of achieving a sense of satisfaction through work
or unstable and sometimes violent family relationships, adolescents living
in poverty often see childbearing as a way to achieve something of their
own. Consciously or unconsciously, they are apt to view a baby as a
source of the love and satisfaction they do not find elsewhere. In some
social milieus, having a baby may represent many things to a young man
and woman: a way to demonstrate sexual competency and fertility, a
sign of adulthood, or a way of relieving the constant stresses of being
poor and helpless. When there is no hope of breaking the pattern of
generations of poverty, there is little motivation to prevent a pregnancy.
Many of these teens may not actively want to have a baby, but they. may
simply let it "happen" because they see little reason to prevent it.
As noted in Chapter 3, despite the evidence that birth control pills are
a safe and effective method for most women, many girls avoid using them
because of misinformation and myths regarding their safety and possible
side effects. Until their questions about the relationship between oral
contraceptives and health and fertility are answered, many young women
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SCIENCE AND BABIES
will continue to avoid using this effective method. What these teenagers
don't understand is that the mortality risk associated with adolescent
childbirth is greater than the mortality risk associated with the pill.
Besides, oral contraception requires a prescription, a visit to a clinic
or private physician for a pelvic examination and a Pap smear, and
funds to renew the prescription every month, conditions that while not
unsurmountable may be enough to discourage an adolescent from using
this effective form of contraception.
In countries where birth control has a high priority, family planning
services and birth control methods are subsidized, so the question of cost
does not prevent their use. Also, a prescription may not be required for
oral contraceptives.
Every form of contraception currently available requires some plan-
ning, and researchers find the reason many teenagers give for not using
contraception is that they did not expect to have intercourse. Other ado-
lescents may not be ready to admit to themselves that they are sexually
active.
Furthermore, each method of birth control currently available in this
country has built-in disadvantages. For example, the IUD might have
been considered feasible as a contraceptive for adolescents because once
inserted it needs little attention. But because the devices have been asso-
ciated with pelvic inflammatory disease and infertility among women who
have more than one sexual partner, manufacturers and epidemiologists
now recommend this method be limited to women who have completed
their families and are in stable relationships. Long-term methods that
might be useful for adolescents are not yet available in this country,
although Norplant is expected to become available in 1990. Foams and
condoms require no prescription but must be used consistently and care-
fully to be effective. Diaphragms and cervical caps require instruction
in use, have substantial failure rates if not used correctly, and are often
viewed as interruptive and messy.
With virtually all methods, younger women tend to experience higher
rates of failure; in fact, women under age 22 are about twice as likely
as women 30 and older to have an unintended pregnancy while using a
contraceptive. The contraceptives available in the United States today are
not very appropriate for the teenager whose sexual activity is sporadic
and often unanticipated. James Trussell suggests:
Adolescent pregnancy could be significantly reduced if a safe, relatively
inexpensive, non-physician-dependent contraceptive were developed for use
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TEENAGE PARENTHOOD
at the end of cycles during which intercourse occurs (thereby eliminating the
need to plan ahead).
91
He adds, however, that such a method would be considered an
abortifacient, and abortifacients are not currently eligible for federal
research and development support. As mentioned in Chapter 3, RU 486
is available in France and China, but its manufacturers have not yet tried
to market it in the United States.
The Use of Abortion
As many studies have shown, almost half the teenagers in this
country who become pregnant each year have an abortion. The health
risks associated with an early legal abortion are no greater for a teenager
than they are for an adult woman. In most instances it is less risky. But
the NRC panel found that in states where a parent's consent is required
an increasing percentage of adolescent abortions are being delayed, often
because the teenager is appealing to the courts for a judicial bypass.
Some states do not require parental consent, but the local providers of
abortion services do. If the abortion is delayed until the second trimester,
the risk to the girl's health increases.
Abortions are performed at 2,680 clinics and hospitals in the United
States, with metropolitan areas offering the greatest access to such ser-
vices. In 1985, 30 percent of U.S. women of reproductive age lived in
counties that had no abortion services at all, and 43 percent lived where
no major facility performed abortions.
The commitment of many European countries to contraceptive ser-
vices for teenagers is strongly connected to the desire of those countries
to reduce the number of abortions among young women. Originally,
conservative physician groups in France and the Netherlands were re-
luctant to endorse the idea of birth control for adolescents. But they
recognized the value of preventive services when it became clear that
the alternative would be a rise in teenage abortions. The 1975 law that
made abortion legal in Sweden also established the basis of a system for
offering contraceptive services to the young, a direct acknowledgment by
the government that the need for abortions could be reduced by making
effective birth control measures readily available. The attitude of these
countries is the opposite of the view held by some groups and influen-
tial individuals in the United States that the availability of contraceptive
services encourages premarital sex and abortion.
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Other Approaches
Some communities and agencies have developed innovative ap-
proaches to averting adolescent pregnancy. These include programs
that teach assertiveness and decision making, strengthen communica-
tion between parents and children, improve school performance, enhance
teenagers' views of the future, and increase their job opportunities.
Programs that seek to improve life options for young people are
based on the assumption that an adolescent who has realistic goals and
a plan for reaching them is less likely to allow early childbearing to
interfere with those plans. Most of the current programs are small and
experimental, however, and clear-cut results are not yet available.
Some efforts are also under way to raise the consciousness of media
executives and help them be more aware of the possible effects on the
young of the sexual attitudes portrayed on television. Such media projects
also aim to encourage a more responsible approach to the sexual content
of programs. More and more professionals and advocacy groups believe
that television portrayals of nonmarital sexuality and exploitive and vi-
olent sex may contribute significantly to attitudes about sex. Despite
the growing concern among professionals and parents, network execu-
tives remain reluctant to include in these same programs any mention
of contraception or abortion for fear of offending the public. In marked
contrast, news programs and talk shows deal boldly with sexual issues,
apparently without losing many viewers. Noticeably missing from daily
TV fare are programs that portray sexuality in a responsible way as part
of stable, long-term relationships. Also missing is national advertising
for over-the-counter contraceptives, such as spermicides and condoms.
In the Netherlands and Sweden nonprescription contraceptives are
advertised widely in the media; adolescents in those countries have a
greater awareness of birth control methods and feel that contraceptives are
easily accessible, although there is no hard evidence that such advertising
actually has increased contraceptive use among teens. Studies do show
that teen pregnancy rates are lower in countries that appear to be less
ambivalent about sexuality.
RESEARCH NEEDS
improving reproductive health in the United States means more re-
search on sexual behavior. Although biomedical research such as that on
the relationship between the hypothalamus and puberty may be useful,
solutions to the difficult reproductive health problems facing this country
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93
are more likely to be found by investigators in the social and behavioral
sciences. Many current intervention programs do not have realistic and
carefully designed evaluation components built into them. It is important
that the outcomes be measurable and that the programs be designed such
that outcomes in the study group can be compared with those of a control
group similar in every way except for the intervention. The definition of
goals and participants and the methods used for making comparisons all
need to be precise for research findings to be considered valid.
Such programs would stand a better chance of being replicated
successfully and funded adequately if providers were willing to scrutinize
their work closely, if researchers were able to evaluate the interventions
precisely, and if schools and other sources cooperated by making available
the data needed to perform such evaluations.
More research is needed to determine:
· the effects of youth employment projects on teenage sexual be-
havior and childbearing; in part, that means making the postponement of
childbearing a stated goal of such projects.
· how and to what extent special programs to improve school
performance are effective in keeping teenagers in school, boosting their
achievements, and averting pregnancies.
· the effect on the offspring of living in a family started by an
adolescent pregnancy, especially as the children grow up. Such research
should control for the relevant background and mediating factors.
· the relationship between early parenting and child development.
· how many adolescents give up their infants for adoption and why
they chose this method to resolve their pregnancies. There are currently
no systematically collected national statistics on adoption.
· the attitudes of adolescent males toward and knowledge of repro-
duction and birth control.
· the connection between what young people know and how they
behave. Programs may be quite effective in raising the level of knowl-
edge about reproductive behavior without having much impact on that
behavior.
· the effect of parental communication and supervision on the
sexual activity of adolescents.
CONCLUSION
Although sexual activity among adolescents in the United States is
on a par with teenagers in other industrialized countries, this nation has
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SCIENCE AND BABIES
a much higher rates of teenage childbearing and abortion. The reasons for
this phenomenon are diverse and not completely defined. However, some
are known: the lack of contraceptive use in the United States among many
sexually active teenagers; the burgeoning poverty rate and the damaging
disadvantages that accompany it; the widespread exploitation of sexuality
in the media coupled with a reluctance to show sexual responsibility and
the routine use of birth control; and the unwillingness of many segments
of U.S. society to discuss sex frankly.
Furthermore, as Guttmacher researcher Elise F. Jones has noted,
political and religious leaders in this country appear to be divided about
what their goal should be: to discourage sex among adolescents or to
concentrate on reducing teenage parenthood by promoting contraceptive
use.
Many programs designed to reduce the incidence of teenage par-
enthood have been undertaken, with unclear results. More projects with
well-planned research components are needed to demonstrate clearly what
does and does not help adolescents delay sexual activity or avoid preg-
nancy. Most often, an unintended birth to a teenager limits her education
and job opportunities. Until we are able to break the patterns of behavior
and economic deprivation with effective intervention programs, teenage
parenthood represents a serious threat to the economic vitality of this
country.
ACKNOWLEDGMENT
Chapter 4 was based in part on a presentation by Daniel Federrnan.
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Representative terms from entire chapter:
birth control
