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OCR for page 176
23. Adolescent Pregnancy
Approximately ~ million teenagers become pregnant
each year; about half of them give birth. Although
the birthrate for teenagers has been declining for
many years, adolescent pregnancy, abortion, and
childbearing are considerably higher in the United
States than in most developed countries."
There are serious health and social consequences
for both teen mothers and their children. Infants of
adolescent mothers under age 15 are twice as likely to
have low birth weight, according to Richard Smith of
the March of Dimes Birth Defects Foundation.2
(~203) These mothers are more likely to experience
toxemia, anemia, and other complications during
pregnancy, says the American School Health Associa-
tion (AS HA). (~006J For young teen mothers (15
and younger), the risk of maternal death is three
times as high as for mothers aged 20 to 24, according
to Walter Ostergren of Life Planning/Health Services
in Dallas.3 (~640) In addition, Smith, Ostergren,
and others report that teenage mothers do not
achieve income or educational levels as high as those
who become mothers later.4 (~006; #~0)
However, the problems associated with adolescent
pregnancies and births must be examined in the social
and economic climates in which most of these preg-
nancies occur. Research has established a strong link
between poor socioeconomic status and early, some-
times socially accepted, sexual activity. In addition,
many witnesses point to the fact that for some
teenagers, pregnancy is intentional. Thus, to have an
impact on the adolescent pregnancy rate, public health
efforts must look beyond the obvious and dramatic
statistics to the broader and deeper social issues that
weigh heavily on this problem.
The 44 witnesses who focused on adolescent
pregnancy and reproductive health highlighted efforts
in several locales-Texas, Detroit, Rhode Island,
Colorado, Los Angeles County, and elsewhere-that
are aggressively combating teenage pregnancy and its
adverse outcomes. They also identified additional
measures that still must be taken or expanded if
targets are to be met. The 1990 goals for reductions
in teenage fertility will not be met, witnesses say.
(~218; #279; #360)
Testimony provided evidence that preventive
strategies can reduce teenage pregnancy rates and
adverse pregnancy outcomes. Smith, for example,
176 Healthy People 2000: Citizens Chart the Course
reports that a program sponsored by the March of
Dimes Birth Defects Foundation at Henry Ford
Hospital In Detroit reduced the neonatal mortality
rate among infants of adolescent mothers from 25.6
per 1,000 to 8.4 per 1,000 over a six-year period.
(i¢203)
However, Denman Scott, Director of the Rhode
Island Department of Health, notes that teenage
pregnancy rates are lower in 32 developed countries
than they are in the United States, despite the fact
that teens begin sexual activity equally as early.5
(#461) Deborah Bastien of Galveston, Texas, adds
that in those countries, family planning services and
sex education are more widely available.6 (~236)
CONTRIBUTING CAUSES
Availability and Use of Contraception
According to Ostergren, there are about 5 million
sexually active teenagers in the United States who
need contraceptives, but family planning clinics serve
only about half of them.7 (~640)
Witnesses note that by the time most teenagers
seek contraceptives, they have been sexually active for
at least a year. Reasons given for failing to obtain
contraceptives include economic barriers and inade-
quate education about contraception and pregnancy.
(#006; #236) For some Hispanic teenagers, especial-
ly those using public clinics, there are additional
barriers; often, they are asked questions about their
legal status, which discourages them from going to
clinics, according to Peggy Smith of Baylor College of
Medicine.8 (~308) Another problem is that teen-
agers may fear visiting a private physician because of
confidentiality concerns. An American College of
Obstetricians and Gynecologists (ACOG) spokesper-
son pointed out that his organization is working to
assure teenagers that they are entitled to guarantees
of patient-physician confidentiality, except in extraor-
dinary circumstances. (#279J
For most teenagers, pregnancy reflects a failure to
use contraceptives or contraceptive failure. Yet for
some, it represents a conscious decision about how to
proceed with their lives. (~003; #308; #640) For
example, among adolescent Hispanic teens in Texas,
Smith says that from 22 to 63 percent of pregnancies
OCR for page 177
are intended. The consequences of out-of-wedlock
pregnancy are seen as "negligible," she says.9 (#308J
Similarly, in the Black culture in Texas, childbearing
is seen as a right of passage into womanhood and the
child is often a source of pride to the grandmother.
Marriage for Blacks was forbidden during slavery and
still is not a social norm. f#797J Unintended preg-
nancies are related both to the unavailability of family
planning services and to a reluctance on the part of
teenagers to obtain or use contraceptives, according to
witnesses. However, teenagers do not always con-
tinue the use of contraceptives once they have been
obtained, according to testimony, and this matter
should be targeted in education and outreach efforts.
Low-income women are more likely to discontinue
contraceptive use than higher-income women, accor-
ding to Diana Bonta of the Los Angeles Regional
Family Planning Council. (#024)
SocioeconomIc Factors
The testimony of several witnesses makes clear,
however, that the issue of teenage pregnancy often
goes beyond contraceptives. What also must be
considered is the social environment and the resultant
self-image and outlook on life.
A number of studies have looked at the relation-
ship between socioeconomic status and teenage
pregnancy or early sexual activity. Although studies
differ in methodologies, populations studied, study
objectives, and so on, many point to the fact that
chronic economic disadvantage may give rise to out-
looks on marriage and family that make early sexual
behaviors acceptable. A number of studies also sug-
gest a strong association between low intellectual abi-
lity, low academic achievement, lack of educational
goals, and early sexual experience among both Black
and White students. Religiousness, on the other
hand, regardless of the faith, appears to lead to
initiating sexual activity at a later age.~°
Edna Batiste of the Primary Care Network of the
Detroit Department of Health describes a syndrome
that characterizes many pregnant Black teenagers that
she sees. The girl's environment involves poverty,
single-parent homes, increasing high school dropout
rates (now 40 percent in Detroit), and unemployment.
She has a baby, drops out of school, and gets a low-
paying job, if she can get a job. She does not want
to marry the father because he has no job, is on
drugs, does not care, or disappears. Welfare becomes
necessary and self-esteem is low. (#016)
Other testifiers agree. Mary Lou Balassone of
Seattle, Washington, states her belief that just like
teen pregnancies, the high rate of repeat pregnancies
"is tied to economic and social factors." (#246)
When a teen becomes pregnant, education is the first
"luxury to be dismissed, followed closely by youthful
dreams and aspirations, according to Cathy Trostmann
of Houston. (#302) Devising strategies for keeping
teens in school is a priority for Jackie Rose of the
Clackamas County Department of Human Services in
Oregon. As an example, she suggests Teaching teens
and their families techniques for success.n (#343)
Bernard Turnock of the Illinois Department of Public
Health calls for "increased education and job training
opportunities to impact the social and economic
factors" contributing to a higher rate of pregnancy
among non-White adolescents. f#215)
PREVENTION STRATEGIES
One approach to preventing teenage pregnancy is sex
education in the schools. Although this topic has
prompted considerable public debate, witnesses did
not reflect the polar views sometimes heard. No one
argued against sex education in schools. Many wit-
nesses, including some who testified specifically about
AIDS or sexually transmitted disease, proposed objec-
tives aimed at including sex education in the health
curriculum beginning in the early grades.
The American School Health Association (ASHA)
says that mandatory school-based sex education has
not been pursued as aggressively as it should because
of the controversy surrounding the timing and content
of such programs. Yet the ASHA notes that Gallup
polls show increasing support for school-based sex
education; recent polls indicate that 80 percent now
favor it with parental consent. The ASH recom-
mends that agencies receiving federal funds for AIDS
education be required to expand their programs to
include pregnancy prevention. (#006) Conversely,
others suggest that information about AIDS and other
sexually transmitted diseases also be included in
education efforts aimed at preventing adolescent
pregnancies.
Some witnesses suggest that the benefits of delay-
ing sexual activity be stressed in adolescent education
programs, but others feel that relying on this message
is not sound. Ezra Davidson, representing the Ameri-
can College of Obstetricians and Gynecologists
(ACOG), comments: "If we adopt an unrealistic and
unbelievable line of reasoning that the only acceptable
behavior is abstinence, we can probably not expect to
see continued progress in reducing unintended teenage
Adolescent Pregnancy 177
OCR for page 178
pregnancies. (~279J Davidson describes arrange-
ments that ACOG has made with the national televi-
sion networks to broadcast public service announce-
ments. These announcements carry two messages:
(I) sex before you can accept responsibility for it is
not desirable; and (2) if you have sex, the responsible
thing is to protect yourself against unintended preg-
nancy. (#279)
Several studies have documented the success of
school-based clinics- that is, primary health care
centers located on school grounds-in helping reduce
adolescent pregnancies. The ASHA cites several
school-based clinics in St. Paul in which birth rates
dropped 40-50 percent, with about 80 percent of
those having babies remaining in school. (~021) In
another inner-city study, junior and senior high school
students received sexuality and contraceptive educa-
tion, counseling, and medical and contraceptive
services at a clinic several blocks from the school.
Among students exposed to the program, pregnancies
increased 13 percent after 16 months; among non-
program students, the increase was 50 percent. After
28- months, pregnancies declined 30 percent for those
in the program and increased 58 percent for non-
program students.~3 (~006J
Bonta says that although the typical client at the
Los Angeles Regional Family Planning Council is be-
tween 20 and 34 years of age, the council has several
goals designed to enhance life options for adolescents,
particularly low-income ones. Its sconces to teens
include providing incentives to defer sexual activity,
programs to reduce unintended pregnancies, and pro-
grams to improve the availability of contraceptives.
She identifies several components of the program:
upgraded family life planning courses, including male
responsibility; programs to improve school perfor-
mance and staying in school; afterschool programs;
programs to improve family relationships or develop
positive adult role models; employment programs;
teen peer counseling programs for the 9 to 12 age
group; outreach efforts to high school dropouts; and
school-based programs to set individual goals, because
REFERENCES
pregnant teens have lower educational and occupa-
tional goals. r#o24'
Other witnesses emphasize the importance of
addressing the larger social context of adolescent
pregnancy. They mention communiW-wide efforts
involving employment and other programs to combat
the problem. `#006; #016; #215' Batiste says that
the classic public health approach, involving teams of
professional community health workers who work face
to face with teens in selected districts, is needed.
These efforts can reach teens who have dropped out
of school, as well as those still enrolled. t~0164
George Flores of San Antonio's Metropolitan Health
District emphasizes the need to involve schools,
churches, and parents in community programs.
(#745)
Prevention strategies should focus not only on
preventing the first pregnancy but also on avoiding
repeat pregnancy, says Balassone. For example, in a
group of teenagers interviewed in 1979, 17.5 percent
of those who had had a premarital pregnancy were
pregnant again within a year. Within two years, 31
percent had a repeat pregnancy. t4 (~246) Donnie
Hanson and Peter Vennewitz of the Washington State
Department of Social and Health Services recommend
adding an objective that the number of adolescents
experiencing second or subsequent births be no more
than 10 percent of those giving birth. (~218)
Other strategies identified by witnesses include
increased availability of family planning services and
contraceptives; increased use of nurse midwives to
provide contraceptive information, because they can
do it effectively and at a lower cost than physicians
(#003~; and enclosing educational material about
preventing pregnancy in tampon and sanitary pad
boxes, as is done for toxic shock syndrome f#360~.
A few witnesses note that recent research suggests
a link between sexual abuse and pregnancy among
young teenagers, and suggest that increased efforts
aimed at preventing sexual abuse of children could
affect the pregnancy rate among young teens. `#215;
#2183
1. Hayes CD (Ed.): Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing, vol. I. Washington,
D.C.: National Academy Press, 1987
2. Friede A, Baldwin W. Rhodes PH, et al.: Young maternal age and infant mortality: The role of low
birthweight. Pub Health Rep 102~2~:192-199, 1987
178 Healthy People 2000: Citizens Chart the Course
OCR for page 179
3. Hughes D, Johnson K, Rosenbaum S. et al.: The Health of America's Children: Maternal and Child Health
Data Book. Washington, D.C.: Children's Defense Fund, 1988
4. Makinson C: The health consequences of teenage fertility. Fam Plann Perspect 17~3~:132-139, 1985
5. Westoff CF, Calot G. Foster AD: Teenage delivery in developed nations. Fam Plann Perspect 15:105-110,
1983
6. Edelman ED, Pittman KT: Adolescent pregnancy: Black and White. J Commun Health 11(1): 63-69, 1986
7. The Alan Guttmacher Institute: Public concerns about family planning programs in teens. Issues in Brief
5~4), January 1985
8. Smith PB: Sociologic aspects of adolescent fertility and childbearing among Hispanics. J Dev Behav Ped
7(6):346-349, 1986
9. Smith PB, Weinman ML, Mumford DM: Social and affective factors associated with adolescent pregnancy. J
Sch Health 90-93, 1982
10. Hayes CD: op. cit., reference 1
11. Louis Harris and Associates, Inc.: Public attitudes about sex education, family planning, and abortion in the
United States. New York: Planned Parenthood Federation of America, 1985
12. Lovick SR, Wesson WF: School-Based Clinics: Update. Washington, D.C.: Center for Population Options,
1987
13. Zabin LS, Hirsch MB, Smith EA, et al.: Evaluation of a pregnancy prevention program for urban teenagers.
Fam Plann Perspect 18~3~:119-126, 1986
14. Hayes CD: op. cit., reference 1
TESTIFIERS CITED IN CHAPTER 23
003
006
016
021
024
203
215
218
236
246 Balassone, Ma~y Lou; University of Washington
279 Davidson, Ezra; King-Drew Medical Center (Los Angeles)
302 Trostmann, Cathy; Houston, Texas
308 Smith, Peggy B.; Baylor College of Medicine
343 Rose, Jackie; Clackamas County Department of Human Services (Oregon)
360 Kopelman, J. Joshua; The OB-GYN Associates (Denver)
461 Scott, H. Denman; Rhode Island Department of Health
640 Ostergren, Walter; Life Planning/Health Services, Inc. (Dallas)
Alden, John; American College of Nurse-Midwives
Allensworth, Diane; American School Health Association
Batiste, Edna; Detroit Department of Health
Blair, Steven; Institute for Aerobics Research (Dallas)
Bonta, Diana; Los Angeles Regional Family Planning Council
Smith, Richard; Henry Ford Hospital (Detroit)
Turnock, Bernard; Illinois Department of Public Health
Hanson, Donnie and Vennewitz, Peter; Washington State Department of Social and Health Services
Bastien, Deborah; Galveston~ Texas
Adolescent Pregnancy 179
OCR for page 180
745 F-lores, George; Metropolitan Health District, San Antonio
797 Chater, Shirley; Texas Woman's University
180 Healthy People 2000: Citizens Chart the Course
Representative terms from entire chapter:
adolescent pregnancy
