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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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70 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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72 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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74 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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76 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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78 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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TEENAGE PARENTHOOD 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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86 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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88 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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9o 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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92 SCIENCE AND BABIES 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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TEENAGE PARENTHOOD 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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94 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. REFERENCES Alan Guttmacher Institute. 1981. Teenage Pregnancy: The Problem that Hasn't Gone Away. New York. Card, J.J., and R.T. Reagan. 1989. Strategies for evaluating adolescent pregnancy programs. Family Planning Perspectives. 21~1~:27-32. Center for Population Options. 1988. Estimates of Public Cost for Teenage Childbearing in 1987. Report written by Martha R. Burt. Washington, D.C. Dash, L. 1989. When Children Want Children, The Urban Crisis of Teenage Child- bearing. New York: William Morrow and Co. Forrest, J.D., and R.R. Fordyce. 1988. U.S. women's contraceptive attitudes and practice: how have they changed in the 1980s? Family Planning Perspectives. 20~3):112-118. Furstenberg, F.F., Jr., J. Brooks-Gunn, and S.P. Morgan. 1987. Adolescent Mothers in Later Life. Cambridge, UK: Cambridge University Press.

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TEENAGE PARENTHOOD 95 Henshaw, S.K., J.D. Forrest, and J. Van Vort. 1987. Abortion services in the United States, 1984 and 1985. Family Planning Perspectives. 19(2):63-70. Jones, E.F. 1986. Teenage Pregnancy in Industrialized Countries. New Haven: Yale University Press. Jones, E.F., J.D. Forrest, N. Goldman, et al. 1985. Teenage pregnancy in developed countries: determinants and policy implications. Family Planning Perspectives. 17(2):53-63. Kisker, E.E. 1985. Teenagers talk about sex, pregnancy and contraception. Family Planning Perspectives. 17(2):83-89. National Research Council. 1987. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, D.C.: National Academy Press. Orr, M.T., and J.D. Forrest. 1985. The availability of reproductive health services from U.S. private physicians. Family Planning Perspectives. 17~2):63-69. Sege, I. 1989. Poverty's grip on children widens. The Boston Globe. March 12, 1. Singh, S. 1986. Adolescent pregnancy in the United States: an interstate analysis. Family Planning Perspectives. 18~51:221-226. Trussell, J. 1988. Teenage pregnancy in the United States. Family Planning Perspectives. 20~6):262-272. Westoff, C.F. 1988. Unintended pregnancy in America and abroad. Family Planning Perspectives. 20(6~:254-261. Winter, L. 1988. The role of sexual self-concept in the use of contraceptives. Family Planning Perspectives. 20(3~:123-127. Zabin, L.S., M.B. Hirsch, E.A. Smith, R. Streett, and J.B. Hardy. 1986. Evaluation of a pregnancy prevention program for urban teenagers. Family Planning Perspectives. 18~31:119-126. Zabin, L.S., M.B. Hirsch, R. Streett, M.R. Emerson, M. Smith, J.B. Hardy, and T.M. King. 1988. The Baltimore pregnancy prevention program for urban teenagers: I. How did it work? II. What did it cost? Family Planning Perspective. 20(4~:182- 192.