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Programs and Policies CHAPTER 9 THE EFEECTS OF PROGRAMS AND POllCTES ON ADOLESCENT PREGNANCY AND CHILDBEARING Sandra L. Hofferth This chapter will explore the effects of a variety of programs and policies on teen sexual activity, contraceptive use, pregnancy and birth. Discussion also will focus on programs and policies concerned with resoldering a premarital pregnancy and with the well-being of young mother s and the ir i Of ants. Although we often think in terms of developing programs and poli- cies to prevent teen pregnancy or to ameliorate its assumed conse- quences, we often tend to overlook the potential feedback effects of programs and policies on teen behavior. Programs and policies have specific objectives: programs for pregnant teens and teen mothers are designed to improve outcomes for child and mother; family planning programs are designed to improve contraceptive use. These are con- sidered to be positive or desirable effects. There may be other un- intended impacts. By reducing the negative consequences of certain behaviors policy makers may be reducing the disincentives to engage in such behaviors. For example, making family planning services available may lead some teens to initiate sexual activity at en earlier age than otherwise. Increasing the availability of welfare may increase the probabili~cy that, once pregnant, a girl will bear and keep her boy rather than have an abortion or relinquish the child for adoption. Providing special programs for pregnant teens and been mothers may increase the probability of a repeat pregnancy. In this chapter rem search on botch intended and unintended effects of policies will be rev dewed . SEXUAL ACTIVITY Several types of programs may delay the initiation of sexual activity and prevent pregnancy. Although all are educational programs, each has a slightly different focus, underlying rationale, and method dology. The f irst type to be considered is designed specif ically to delay sexual involvement. Pro jects currently funded by the Off ice of Adolescent Pregnancy Programs fall into this category. These programs are primarily educational, but have a specific purpose, which is to delay sexual intercourse. One type of project focuses on helping 207

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208 young people develop skills to be able to avoid sexual intercourse. Another type of project promotes parent.child communication as a means to delay teen sexual involvement. A second type of Frog ram attempts to prevent early involvement in sexual activity and early pregnancy by making young women aware of career options and life choices other than motherhood. It attempts to raise young women's self-esteem and sense of control over their lives so that such alternatives can become realistic ones. Three prog rams that fall into this area include Pro ject Choice, the Association of Junior Leagues programs, and the Girls Clubs programs. A third type, the most common, falls under the heading of sex edu- cat~on or family life education. The major goals of sex education are to promote Irrational and informed decision-making about sexuality. and to ~ increase a strident ' s knowledge of reproduction. (held by 97 percent and 77 percent of school districts respectively). Fewer than half c ited a desire to reduce teen pregnancy and only 25 percent cited a goal of reducing teen sexual activity (Sonenstein and Piteman, 1984~. A fourth type is a combinat ion of traditional sex education with some new techniques which focus on training students in problem-solving and decision-making skills as well as assertiveness skills so that They can implement the decisions they make. These decisions may include avoiding sexual in`?ol~rement, or selecting contraception (Schinke et al., 1981) . Such a project may reduce early sexual involvement , but that is not its primary goal. Promotion of Abstinence A major project Postponing Sexual Involvement. underway in Atlanta, Georgia, directed by Marion Howard of Emory University, has as its goal educating adolescents concerning self-discipline and re- sponsibility in human sexuality (Howard, 19841. The program, which is designed to help young people (under age 16) resist pressures to become sexually active before they are ready for such involvement, or is inally consisted of a ser ies of four workshops for young people and an option- al ser ies of workshops for their parents. Each 90 minute session in- corporated factual information and participatory activites designed both to increase knowledge and to build a specif ic set of skills. Session I focussed on social pressure, Session I] on peer pressure, and Session III on problem solving. Session IV, conducted three to six months later was designed to reinforce the skills learned. The critical features of this program are 1) a base in developmental theory, 2) a clear value base, 3) skill-buslding exercises and activi- ties as *11 as provision of information, 4) use of peer and parent support The program was first f~eld-tested in Atlanta and Cleveland, after wr.~_h two curricular;- guides and a companion slide~tape presenta- tion were developed. The project is currently being implemented in the Atlanta public schools as a six-week course for all eighth graders. No evaluation data are yet available.

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209 The office of Adolescent Pregnancy Programs is funding a series of 21 projects which have as their goal the prevention of sexual activity among young teens through improved parent-child communication. One such project has as its goal To enable parents to better communicate their values and attitudes regarding sexual behavior to their children and to help their adolescents develop positive self.concepts and in proved decision-making skills to enable them to exercise greater re- sponsibility over their sexual behavior. (Montana State University, Bozeman, MT). Another project will offer a values based Life and Family National Demonstration Project to parents and their adolescents for the purpose of promoting sexual restraint among teenagers (Search Institute, Minneapolis, MI). The majority of these projects have just begun; evaluations are not yet available. However, it is apparent f ram a review of their evaluation plans that although most will measure parent-child communication and related attitudes and values, few will actually measure the impact of the program on the sexual activity of the teens who participate. Thus a major test of the effectiveness of such programs will not result f ram this research. In 1981 and 1982 the State of California tested and then imple- mented a Family Communication Prog ram in two regions of California, f irst in the Fresno area and then in the San Francisco Bay Area {Solem and Associates, 1982) . The pr imary goal of the Family Communication Program was to increase the frequency and improve the quality of parent-child communications about sexuality and thereby ultimately to reduce teen pregnancies in California. The immediate objective was for parents of children ages 10 to 17 years old to initiate a verbal communication or increase the number of verbal communications with their children about sexuality. The program made no attempt to mandate the content of those family communications; rather existing community groups were used as vehicles to facilitate and direct such cosmunica- tion. The media campaign used radio and television advertisements, publicity, printed materials and encouragement and publicity for local organizational activities held concurrently with the publicity cam pa ign. An evaluation of the program was conducted concurrently (Public Response Associates, 1982). This included pre- and post-program public opinion surveys, conducted by telephone . The evaluation showed an increase of 14 percentage points in those parents who ruse every opportunity. to teach their children about sex, ~ and a decline of 11 percentage points in the number of parents who say that their children initiated more discussions on sexual topics than they did. There was no overall change in attitudes towards sex education, although a slightly increased proportion thought parents were responsible for their children's sex education. The impact of the program was greater in the Fresno area than in the San Francisco Bay area, probably bee cause the prog ram reached more people in Fresno and because San Fran- cisco area parents were better communicators before the program. Finally, television was shown to be more effective than either news- papers or radio in reaching the public.

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210 Life Options Approach The Tent of Project Choice is to support and help young women explore future careeer options other than young motherhood (Alexander, 1984). It focuses on making at-risk young women more aware of the variety of life choices which are or can be, available to them. The structure of Project Choice is that of an extra-curricular club with voluntary participation. Meetings are held weekly. Activities are d irected toward the development of educational, career and general life options, not simply towards contraceptive behavior. Clubs are composed of students who may not yet be sexually active, as well as of students who are sexually active or who may already be parents. S. Once these prog rams are relatively new, few evaluations have been conduc~ced . The evaluation of Pro ject Choice showed no signif leant imp pact on any of its stated goals {Alexander, 1984 ~ . }however, the ev~l- uation of the program was not very rigorously conducted: the control groups were poorly constructed, the nature of the intervention was not clearly delineated, and the outcome measures were abstract. -Only a small number of young women participated ~ n this pro ject. Thus it can be concluded that this evaluation could not adequately evaluate the success or failure of this type of intervention. The Girls Clubs have developed an experimental program that started about March I, 1985 and will last three years (Quinn, 1985~. Eight girls clubs across the United States were selected. Four were assigned to the experimental and four to the control condition. All projects received a baseline (pre~test) and will receive a follow~up (post-test) instrument, but in only the experimental group are the programs being implemented. The program consists of 4 components, each of which will be implemented at each experimental site. Since the Girls Clubs in- clude girls of a wide range of ages, different components will be di- rected at different age groups. As the girls age, they will move f rom one component into another. The first two components are directed at 12 to 14 year olds. The first component consists of a parene-child program which is directed toward increasing communication about sexual issues and values. The specific mechanism will be ~nother-daughter workshops. The second component, consisting of specif ic interventions with young adolescents, is designed to postpone their sexual invol~re- ment. This part is modeled after the Atlanta program directed by Marion Howard. The third and fourth components are directed at older adolescents (ages 15 to 171. The third component consists of a proj- ect ~Choice.. developed by the Santa Barbara Girls Club. to help girls develop career and educational aspirations. The program approach is designed to engage participants in a set of act ivities that will chal- lenge them to think about their own futures, : ~ the areas of family life and work outside the homer These activ - As include conducting interviews, developing family ~: ~gets, Sylvia puzzles, writing con- clusions for hypothetical life ~ or ies ~ using classif ted ads to seek housing and employment, car ing for a baby, conducting a ~ersons1 skills inventory, developing a set of personal goals and objectives, and

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211 developing an individualized plan for reaching these goals (Quinn, 1984~. A book entitled Choices, a workbook for young women that is based on the course's content and format, has been published. (A come parable book for males has also been developed.) An evaluation of Choices began in 1984 but no results are yet available. The fourth component of the Girls Clubs programs is the Clinic bridge. between educational and clinic services. This is modeled on the comprehensive school-based program developed by the St. Paul, Minnesota, Maternal and Infant Care Pro ject . Educational and clinic services will be of feted, perhaps on the club site, to club members. Traditional Sex Education Information can sex education in schools cones from two major national studies. According to a lB82 survey of 200 school districts in large US cities conducted by the Urban Institute and jointly ad~sn- istered by the National Association of State Boards of Education, three quarters of school districts offered some sex education (not necessar fly a separate course) -- in their schools (Sonenstein and Pitt- man, 1984~. A 1971 survey by the National Institute of Education found that only 36 percent of public high schools offered a separate course in family life or sex education (Orr, 1982~. Most schools integrate sex education into the material in other courses. These data are consistent with reports f ram individual adolescents, of whom three quarters report some sex education instruction before leaving school {Zelnik and Rim, 1982~. School districts are remarkably in agreement on the goals of sex education. N inety four percent ag ree that a ma jor goal is to promote rational and informed decision-making about sexuality; 77 percent agree that a goal is deco increase a student's knowledge of reproduction. 25 percent say that a goal is to reduce teen sexual activity and 21 per- cent say it is to reduce teenage childbearing. Nine of ten districts include physical differences between males and females, pregnancy and childbirth and sexually transmitted diseases in their curriculum. Th ree quarters include information on sources of contraceptives and on personal or moral values, while only half include information on mas- turbation and homosexuality, and almost none include information on sexual techniques {AGI, 1983; Orr, 19827. E f fects of Sex Educat ion Sex education is designed primarily to enhance knowlege. That is, it is designed to improve students' knowledge and understanding about how the body functions and about human sexuality. Some courses are also designed to understand the sac ial context of sexuality, including relationships with others and the social, moral and ethical constraints on its expression A successful course should be expected at a minimum to inc rease knowledge in the areas taught. And this generally Is found

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212 to be the case. Numerous studies f ind the same thing--courses in human sexuality and family life do increase students' knowlege about the subject (Kirby, 1984; Eisen et al., 1985; Finkel and Finkel, 1984) . Sex education may also affect attitudes, but research to date has documented only limited effects. On the one band sex education appears to make students more tolerant of other s' attitudes and behavior; on the other hand it has not been found to alter the individual's personal attitudes and beliefs (Kirby, 19841. However, it is precisely this concern that has led many sex educators to focus more attention on dis- cussion of personal and moral beliefs and values about sex and sexual- ity, to make sure that students understand the context of their person- al beliefs, even if other students have different beliefs and values. Although receiving sex education has the strongest statistical association with increased knowledge, there is substantially more in- terest in how sex education affects behavior. In particular, there is concern that sexuality education promotes early or more frequent sexual activity among teens that take such courses. There is also concern that it may not be effective enough in promoting effective and respon- sible contraceptive use among teens sexually active, in particular, effective enough to counteract the alleged incentive effect on sexual activity. Finally, there is interest in identifying, among those exemplary programs, programs that appear to be most successful, and the characteristics that are associated with these successes. Bere, as before, we focus on the effects of these programs on sexual activ- ity, contraceptive use, and premarital pregnancy and pregnancy resolution. In an analysis of the effects of having had sex education in high school among a national sample of 15 to 19 year old females in 1979, Zelnik and Kim (1982) found no association between the probability of initiating sexual activity and having had sex education; however, for those who were sexually active, those who had had sex education were more likely to contracept and less likely to become pregnant than those who hadnt t. This study was based on survey responses, with only a limited set of questions to measure whether the respondent ever took a sex education course, and with no measure of whether the course Is taken before or after the behavior examined. However, the authors believe that the lack of information on the ordering of events prom duces a conservative bias. That is, the results are weaker than they might have been with more appropriate data. Unfortunately, with the data available it is impossible to tell what about the program or prom g rams night have led to this result. Thus the results are useful but not def inn' ive. There are several fairly recent studies of sex education that are of interest. The Arkansas Family Planning Council (1983} conducted a study of the impact of instituting sex education in about one~third of its schools. ~ t found that births declined at a faster rate f ram 1918 to 1981 in areas where students received sex education than in areas

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213 where they did not. Unfortunately, a reanalysis of tints data by Doug Kirby (personal communication, Februrary 198S) for that office found that after controlling, for other factors there was no residual impact of the sex education program. }t is likely that initial differences between counties, rather than the sex education program, led to the initial conclusion that the program had been successful. A three~year study of Family Life Education was conducted in 1979- 81 in 12 California School Districts by ETR Associates (Cooper, 1983~. The study found that the program was highly effective in increasing students' knowledge and enhancing students' self esteem and decision making skills, in increasing parent-child communication and even in reducing pregnancy rates. Unfortunately, the study did not have a control group. As a result, it is not possible to assess whether or not the control group' s knowledge, skills, etc., would have improved and their pregnancy rates declined as well. This is not a trivial concern since the K irby study ~ reported below) found that changes aver time in the control groups squalled changes in experimental groups. Mathtech Study The most recent evaluation of sexuality education programs was conducted by Kirby (19847. The major purpose of this research was to f ind, develop and evaluate promising approaches to sexuality educa- tion. (Kirby, 1984:47~. Accordingly, and guided by numerous experts, promising programs were selected and improved, before the evaluation was begun. Kirby focused on 12 exemplary programs in nine sites around the country (some sites have more than one program}. Four of these programs were school-basea, constituted a separate course, and were at least one semester in length. Five were short programs pre- sented either in the school, in community centers, or other locations which lasted f rom 5 to 10 hours, either in one day or over several weeks. Three additional programs one a peer education program, a second a parent-child program, and the last a combination education/ clinic program in a school setting--were also examined. In all of the non-clinic sites, data were collected prior to the course, imme- diately after the course ended and then 3.S months later. Control groups were selected for each program. The changes across each site over time were compared with changes in the control group to determine the effects of each program. Most programs increased students' knowledge. Classes with younger students learned more than those with older students. Surprisingly, the longer courses did not appear to improve knowlege more than the shorter courses. However, there were a number of important differ- ences between short and long programs, including different lengths of follow-up periods, different control groups, and differences in par- ticipants and curricula, that might have resulted in this unexpected result.

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214 Only in three short programs at one site did clarity of values in- crease. Most programs did not increase clarity of long term goals, clarity of persons} sexual values and understanding of personal rem sponge to sexual situations. In general, the programs did not increase liberality or permissive ness of student's attitudes toward premarital sex. In contrast, the attitudes of the control groups did become slightly Snore liberal. Programs did not affect attitudes toward the importance of birth control. Atitudes were positive and high in experimental and control groups. Scores of both groups increased. Few impacts on other attitudes, such as toward gender roles, sex- uality in life or the importance of the family were found. There was in some programs an increase in opposition to use of pressure and force in social and sexual relations. There was ~ ittle impact on self esteem, little impact on skills in social decision-making, communication, sexual decision-making and come munication about birth control. The only program to increase comfort talking about sex, birth control, sexuality with parents, and the free quency of reported conversations about sex, birth control with parents, friends and boyfriends was the parent.child program for young children. There was little impact upon comfort with other social and sexual activities. F inally, there was no impact of the prog rams on sexual behavior, contraceptive use (frequency of sex without birth control or effective ness of birth control, or pregnancies. Student and parent assessments of the courses and their impacts were generally positive to enthusiastic. Recent Analyses of National Surveys Because of the lack of national surveys with information on sex education ever received, in the last five years questions were added to the number of national surveys which included teenagers. Recently, analyses of these new date sources have become available. Questions on whether the respondent ever had a sex education course, as well as information on sex activity and with whom ever talked with about #X were included in the 1981 wave of the National Survey of Children, a survey of children who were 12 to 16 at the time. A subset of teens 15 to 16 were analyzed (Moore et al., 19851. The authors found a sig- nificant association for white males and females and for black females, such that those who had received sex education were less likely to rem port that they had had intercourse, and this association held up when controls for family income, mother' s education, the mother' s age at f irst birth, family structure, and community size were included. The

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215 only group ache association did not hold for was black males. However, with no information on the timing of either the sex education course or first intercourse in these data, a causal relationship could not be tested. The National Survey of Family Growth included questions not only on whether the respondent had ever had sex education, but whether the course included instruction on methods of birth control and the age of the respondent when that instruction took place. In addition, the month and year of first intercourse was obtained. This allowed the researcher (Dawson, 1986} to establish the timing of sex education with regards to intercourse for all respondents except those who rem ported contraceptive education and f irst intercourse at the same year of age. As a result the researcher tested two models: the first made the extreme assumption that all women receiving formal contraceptive education at age x received that education at the start of that year of age, i.e., at exact age x. Under thin assumption all women whose first intercourse occurred during the same year an sex education would have received the sex education f irst. The second model made the equally extreme assumption that all women receiving formal contracep~ tive education at age x received that education at the end of that year of age. Under this assumption none of the women would have hem ceived sex education before f irst intercourse. The author found no effect of having received sex education under the latter assumption. Under the f irst assumption they found one signif Icarus effect: 14 year old s who had contraceptive education by exact age x were Snore likely to initiate sex within the next year. None of the coefficients for the other single~year-of-age groups ~15, 16, 17, 18) were signif icant. These results held controlling for factors such as race, parental edu- cation, and religion that are also associated with early initiation of sexual intercourse. The author concludes that no evidence for a causal effect of contraceptive education on first intercourse was found in these data. However, the author found evidence that having had contraceptive education is associated with contraceptive use at f irst intercourse. Under both the above assumptions those who had contraceptive education were more likely than those who had not to use a contraceptive method at f irst intercourse. Those who had ever had contraceptive education were more likely to have ever used contraception. The authors found no ev idence for a d irect effect of contraceptive education on the p robabil ity of a premar ital pregnancy . The third study was conducted on data from the National Longitu- dinal Survey of Youth, 1984 wave (Marsigilio and poet, 19861. In that year questions were asked about whether the youth had had a course related to sex education and whether it included information about contraception, the female monthly cycle and so on. In addition it asked the month and year in which the first such course was taken. The survey also obtained the month and year in which the respondent first had sexual intercourse. Thus this surrey provides the best

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216 possible information to precisely determine the thing of first inter- course relative to a sex education course. The authors found thee females who had a sex education course prior to their 15th and 16th birthdays, respectively, were more likely to have had intercourse during their 15th and 16th years. The coefficients were large and statistically signif icant, net of a number of other factors also found to be associated with initiation of sexual intercourse, such as race, church attendance, parental education, and birth cohort. The coeffi- cients declined in size and were no longer statistically significant at ages 17 and 18. The authors interpret these results as providing some evidence that sex education can increase the probability of en- gaging in sexual intercourse at young ages. On the otter hand, there may be factors associated with instituting sex education at an early age that are also associated with early sex, such as characteristics of the school or community that are not controlled. If so, then the relationship could be spurious. This is the first rigorously conducted scientific study to suggest that sex education nay be associated with increased intercourse, thus it is an important one, but more research should be conducted to test the thesis. Since the data were obtained in a survey instrument, only a very minimal amount of information about the course could be obtained. In particular, there was no in- formation about the length of the course, or any of the other factors that were considered in the Kirby (1984) study of a number of model p rog rams. These authors (Most and Marsiglio, 1986) found some evidence that having had a sex education course was associated with a higher likeli- hood of currently contracepting among 17 and 18 year old women; how- ever, the measure of contraceptive use available in the data is very limited. F inally the authors explored but found no relationship be- tween having had a sex education course and whether had a premarital pregnancy after taking that course. The signs were negative, but the chef f ic tents were not signif icant. Assert ivene ss/Dec i. ion-Male ing Approaches Schinke and Gilchrist {1984} and Schinke et al. (1981) have been utilizing what they call a Life Skills Counseling approach with adoles- cents. Its six components include information, proble~solving, self- instruction, coping, communication and support systems. Schinke and colleagues argue that pregnancy prevention requires adolescents to think analytically and rationally about their sexual behavior. To do so they need not only factual information, but also proble~solving and decision-~king skills and interpersonal communication skills so as to be able to inclement those decisions. Schinke and colleagues have implemented a number of programs utilizing this approach. These prog rams provide information, but they also train students in problem solving and decision-making skills as well as assertiveness skills so that they can carry out their decisions. For example, if ~ youth den c ides to avoid involvement in sexual activity, he or she will have the

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217 skills to resist pressure to participate. In contrast to the Howard project, the Schinke project takes no explicit value position on bee havior. Each individual develops his/her own goals and objectives. The Schinke project also includes contraceptive decision-making and teaches assertiveness in active sexual relationships. The skills emphasized in the course are taught through modeling, role playing and rehear salt The Schinke pro ject ( 1981) has evaluation cat. for ~ total of 44 subjects in the experimental condition and 49 controls. Data from the six, nine and 12 month follow-ups show that the youth who took the course had better problem. solving and communication skills, and more knowledge of reproduction and birth control than those who didn't. They also had more favorable attitudes toward family planning, more habitual contraception, greater protection at last intercourse and less reliance on inadequate birth control methods than untrained teens (con- trol group). Unfortunately, no information on sexual activity was reported for these subjectse Sugary In summary, research conducted on young men and young women has shown that sex education increases knowledge about sexuality; however, the evidence for an impact on behavior is weak. Assertiveness/dec i- s~on-making approaches along with sex education look promising, but have not yet been adequately evaluated. Life options approaches are new and lack evaluation. Finally, research has shown that special parent-child programs can and do result in increased parent-child cow municatzon about sexuality, at least for a short period following the program ~ see Kirby, 1984: 317-350) . However, support for the hypothesis that communication reduces teen sexual activity is weak (see Fox, 1980; Newcomer, 1983; Kahn et al., 1984, and discussion in Chapter 1) . Un- fortunately, a major test of the effectiveness of such programs will not result from the research described above because of weaknesses in the evaluation designs. Male~fem~le differences in responses to these pros rams have not been explored. CONTBACEFTION/PP~GNANCY p8'E1rENTIcN The types of programs that are directed at contraceptive use and pregnancy prevention include the assertiveness/decision-making ape proach, sex education, family planning services, school-based prom grams, and non-school based multi-purpose youth centers. Assertiveness/decision-~aking approaches were covered in the previous section. Schinke et al. (1981) found a significant program impact on contraceptive use at the six month follow-up. The charac~ teristics of sex education were reviewed in the previous section and won't be reviewed here. As described earlier, according to the most

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253 groups are simply other adolescent pregnancy programs. Yet it is not entirely clear what services the adolescent received in each of the separate programs mentioned and how they might differ. In any case, using other programs as camper isons would seem to reduce the likeli- hood of finding significant program effects. Prenatal/Early Inf ancy Pro ject This study evaluated a comprehensive nurse-home visitation and transportation service designed to improve pregnancy outcomes and child health and development in a group of families at risk for preq- nancy and childrearing dysfunctions. The nurse home-visitation pro- 9 ram began dur ing pregnancy and followed the families through the second year of the child' s life. Mothers of all ages were included in the study, but analyses were conducted and data tabulated separately for high risk groups (e.q., adolescent mothers). The study consisted of a true experimental design, with families randomly assigned to one of four treatment groups. Families in the first condition received no services dur ing pregnancy (other than the excellent quality standard prenatal care provided locally). Screening was provided at 12 and 24 Camel it in the second condition received free transportation to regular prenatal and well-child visits as well as the screening offered the f irst group. Families in the third condition received nurse home visitation during pregnancy, in addition to transportation and screening. Families in the fourth condition received nurse home visitation during the children's first two years of life, in addition to the prenatal home visitation, transportation, and screening offered the third group. months. ~ ~.._~ The ma jar d if ferences in treatments were between the f irst-second and third-fourth groups. Treatment effects were strongest for the highest risk groups--adolescents, smokers and unmarried women. The nurse-visited young (14-16) adolescents gave birth to newborns who were near ly 4 00 ~ rams heavier than those born to adolescents in the comparison group. 89 percent of the poor unmarried, young mothers ~ under 19) who were visited by a nurse had either completed or returned to school, compared to 52 percent of those comparable mothers who had no nurse. There was essentially no reduction in the incidence of rem peat pregnancy among adolescents. This is a very well-done, interesting study of the impact of an innovative progress. It takes a number of factors placing women at risk for poor maternal and child outcomes and considers their effects both jointly and separately. It is especially good because smoking is included as a risk factor. The results show clearly that the program has some positive benef its for adolescents; the benef its for older women, particularly married women are less clear. The random assign- ment feature and the use of different types of treatments is very good. Unfortunately, since most women can obtain excellent care through exis- ting services, the effect of the treatment is really only marginal.

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254 Thus the fact that some effects are signif icant among important sub- groups such as adolescents is important. In addition, since the prom gram included women of all ages, the the sample of ur~married women under 18 consisted of only 112 cases, which were divided into 4 dif- ferent treatment groups. However, the fact that significant effects were found is encouraging. Compa r ~ son of These Evaluat ions One of the important contributions of Klerman and Jekel' s evalua- t ion was methodological. ~ t constituted a very careful analysis of the effects of pros rams and served as a model for later analyses. Substan- tively, it shower! clearly the decay of short term gains that resulted f rom a prog ram, and it pointed out the importance of distinguishing be- tween short.term and long term effects. Finally, it pointed out the importance of looking at repeat pregnancies as an important outcome. Women having repeat pregnancies were especially at risk of undesirable outcomes The Project Redirection staff also discovered the importance of focusing on delaying repeat pregnancy. They did not focus much iJnpor- tance on it at first, but, soon alarmed at the number of repeat preg- nancies, began putting more pressure on participants to contracept effectively. Project staff monitored contraceptive use and the coo munity woman checked up on participants assigned to than. In one site (Phoenix) , teens who became pregnant again were terminated (see Branch et al., 1984:49) . The issue of repeat pregnancy is a tough one for programs. Klerman and Jekel noted how hard it is for a pregra~/it. personnel to say 1) you can postpone the text baby if you want to but 2} if you become pregnant again come see us again early. They hypothesized that perhaps young mothers felt guilty about returning pregnant to a program which had stressed contraception, and that is why subsequent pregnancies had less adequate prenatal care {Klerman and Jekel, 1973:68~. (On the other hand, it may simply reflect a selection problem--the most care- less girls become pregnant again, although Xlerman and Jekel didn't seem to think this was so, Rlerman and Jekel, 1973:681. The contribution of the American Institutes for Research evalua- tion of Project Redirection was also methodological it represented a very careful evaluation of overall program impacts over a relatively short term {24 months}. However, there was no possibility of deter- mining which aspects of the program produced which results. Later analyses to sort out different program aspects and their impacts would be helpful, especially since there were a number of innovations. The effect of the community woman would be particularly helpful to know. The contribution of the OAPP evaluation we. precise!" the attempt to look at the contribution of specific services provided teens. Un-

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255 fortunately, this evaluation was not capable of determining overall prog ram impact because of the lack of a control g Coup. The Prenatal/Early Infancy Project represents the trend toward more rigorous program evaluations. Subjects were randomly assigned to treatment/comparison groups; several types of interventions were tested simultaneously; and a number of risk factors were considered simulta- neously in looking at outcomes of the proje. t. In addition, the proj- ect was located in one area, treatment conditions were uniform across all subjects in each condition, and the project was relatively modest in size, but not too small for effective evaluation. This pro ject appears to provide a valuable model for other evaluation.. Probably the most important contribution was to show that separate aspects of the program could be evaluated at the see time by developing dif- ferent t reatment conditions. The Too Early Childbearing Network has serious problems in develops ing effective evaluation because of lack of appropriate local control groups. The national data are useful, but are hard to mace comparable enough ~ in terms of race, age, SE:S) to be of use. The McAnarney Project was simply too smell for effective evalua- tion. The evaluation of the Johns Hopkins program mixes evaluations of different types of programs and does not clarify what types of ser- vices are being provided in which program. As a result, the conclu- sions are weak and unclear. Finally, not enough information is in- cluded in the description of the JRB Associates program evaluation to adequately evaluate it. Economic App roaches One major barrier to the participation of males in teenage father programs is that services often fail to meet their real life needs. ~Commonly, young men will not enter a program unless it provides them with job-related skills and training; they will not stay in a program over time unless it helps them deal with their more personal, relation- ship~oriented problems. (Rlinman et al., 1985: 14} . This suggests that a substantially different type of program is needed to attract and keep males than programs traditionally oriented to teenage motbere. Job training should constitute a major part of such programs. An appropriate set of services such as legislatively mandated for teenage mothers has not been established for teenage fathers. Delaying family formation or preventing repeat childbearing has not been a primary goal of job training programs. In fact, most prom grams appeared to ignore the family responsibilities of enrollees, in spite of the fact that a large proportion of male and female partici- pants have children of their own. AS a result, there is not much evi- dence as to the impact of such programs on teen childbearing. One evaluation of the Job Corps conducted by Mathematics Policy Research

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256 found that, among young waken, participation in the Job Corps appeared to delay family formation and reduce the incidence of extramarital childbearing, and that the impact on employment, earnings, education and welfare receipt was larger for women without children than for those with children (Mallar et al., 19787. A second study which promises to provide more information on the impact of youth programs on family formation is one currently under way by Olsen and Farkas. The program whose data they will evaluate is the Youth Incentive Entitlement Pilot Projects {YTEPP). This program guaranteed jobs to 16 to 19 year olds enrolled in school if they stayed in or returned to school and met specif fed attendance and performance standards (from Simms, 1984~. Although early results suggested no in pact of the program on the rate of childbearing (which was high) among females, a three year study cited above will analyze these data in greater detail, looking for impacts among certain groups of partici- pants (O lsen, 19 84 ~ . ~ third project, the Teen Fathers Project, was conduc~ced between April 1983 and March of 1985 by Bank Street College in 8 sites around the country. This project obtained teen fathers through their female partner, outreach workers, the school, YOGA and word of mouth. Some 400 teen fathers received job training, job skills, job referral ser- vice, educational counseling, and instruction on site in parenting skills. The goal of the program was a OCR for page 207
25, Ration f ram school records each semester, and a f inal interview 6 months after putative graduation date. Tbe control group receives full-t ime sunder work, but no other intervention. The f Or st phase of the program was implemented in 1985-86 with 1,600 youth in 5 U.S. cities. Results from the f irst shower of the program show that the program had some positive impacts on enrollees. In particular, the programwas successful in stewing the learning losses that would have occurred in the absence of the treatment. While treatment youth scored higher than control group youth at post-test in both reading and math, both groups experienced losses. The losses experienced by the control group were significantly larger than those experienced by the treatment group. Females and Hispanics appeared to benefit the most from the progr - . Participants' knowledge of birth control was increased. Finally, more treatment boys reported abstaining from sex during the program than cant rol boys. Welfare and Medicaid AFOC is the major federally funded and state administered welfare program in the United States. It provides cash assistance to economi- cally needy individuals who are eligible by virtue of being a female f amily head with children under 18, and meeting certain income require- ments. Female subf daily heads are also eligible for themselves and their children or for their children only. Some states have instituted a program which makes eligible families in which the father is present but unemployed and who also fall below a certain minimum income level. Medicaid is a health insurance program available to all AFDC recipe tents. There has been a considerable attention paid to the hypothesis that generous transfer payments create an economic incentive to early childbearing. It is not possible to test empirically whether the existence of transfer payments under the AFDC prog ram af feet early childbearing, since all states provide transfers under the program. However, there is substantial variation in level of payments and in eligibility requirements, which are reflected in acceptance rates, and these can be related to fertil ity levels. This debate has a long history, going back at least to the late 1960s. A study by Placed and Hendershot (1974} that tested a numt~er of propositions drawn from this belief for welfare recipients of all ages found no support for whet has been called the ~Brood Sow. myth. In fact, they found welfare mothers more likely to use contraception when an than when not on welfare, less likely to define pregnancies as wanted, and less likely to have a subsequent pregnancy when on than when not on welfare. Of course, this paper did not specifically ad- dress the issue of teen childbearing. In an early study of out-of- wedlock birth rates in 58 SMSA's, Janowitz (1976) found that a higher

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2S8 level of state welfare benefits was associated with higher out-of- wediock birth rates among teenagers, net of other factors such as level of schooling, earnings and unemployment. Howeve r, whether the state also had a unemployed fathers program in APDC{AEDC-U) was also found to be associated with higher out-of-wedlock birth rates for teenagers, a counter-intuitive finding. Thus the A!DC variable may be a proxy for variables which are associated with it, but which are not controlled in the model. This is especially a problem for this analysis since AE33C payments are only obtained at the state level, while birth rates were measured for each SMSA as a whole. Several recent studies have tested the association between welfare and teen childbearing. None found any impact of either level of AFOC benefits or acceptance rates on out-of- wedlock birth rates among teens in 1971, 1974 or 197S (Field, 1981; Moore and Caldwell, 1977; Moore, 19801. Moore and Caldwel1 (1977, also explored the impact of AFDC benefit lent and acceptance rates on initiation of sexual activity, pregnancy and pregnancy resolution among teens. They found weak and inconsis- tent effects which led them to conclude that there was no association between welfare generosity or acceptance rates and the probability of initiating sexual activity or becoming pregnant. However, they did find effects of relatively generous AFCC benefit levels on the proba- bil ity of abort ion. Teens in states with relatively generous benef it levels there less likely to have an abortion. ~~ the other inane, teens in states with low AFoC acceptance rates were- . fund to ha: a higher probability of bearing an out-of-wedlock chilly The author .~ concluded that there was no s~catistically signif leant evidence linking welfare availability with the probability of carrying an out-of-wedlock preg- nancy to an out-of-wedlock birth (Moore and Caldwell, 1977 :166-167) . The authors also looked at the impact of having an unemployed father prog ram on pregnancy resolut ion. They found that women in states with such a program were, in fact, no more likely to marry, but were less 1 ikely to bear an out-of-wedlock child. Recent analyses of California data collected in 1972-74 (Leibowitz et al., 1980 ; E isen et al., 1983 ~ found that premaritally pregnant girls receiving state f inancial assistance "welfare) were less likely to marry and more likely to bear an out-of-wedlock child than compa- rable girls not currently receiving such assistance. This study is f [awed. The ma jor problem is that eligibility for welfare receipt is measured by current welfare receipt. In fact, many of those young women not currently on welfare would be eligible if they gave birth to a child out of wedlock. This measure of welfa~,~; availability is probe ably contaminated by attitudes toward welfare recipiency, by awareness of welfare availability- and by prior intention to carry out or abort the pregnancy. Those intend ing to bear a child out-of-wedlock have a greater incentive to establish welfare eligibility than those act plan- ning to bear the child. Thus the causal direction of the assoc~ --ion is unclear (Moore and Burt, 19821.

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259 A recent study by Ellwood and Bane (1984) used data from several large nationally represen~cati~re data sets, the Survey of Income and Program Participation, and the 1960 and 1970 Censuses to explore the impact of welfare on AFDC on divorce and separation, births to non- married women, single parenthood, female headship and the living arrangement of single mothers. The study differs from the others den scribed earlier in that it controlled statistically for a number of unmeasured differences between states. In addition, it used three dif- ferent types of methodolog ies to answer the question of the inspect of AFOC: a comparison of likely versus unlikely recipients, of eligibles versus non-elig ibles, and of APDC benef it levels and changes in family and household structure and fertility over time. The authors concluded that they could isolate no impact of the maximum AFDC benefit for a family of four on births to non-rearried women. However they did iden- tify several effects on family and household structure. In particular, divorce and separation rose slightly with a SIOO increase in the AFDC maximum benef it, as did single parenthood and female headship. The largest inc rease was in the probability that a young single mother would live independently, an increase of 50 to 100 percent in one analysis. This analysis supports previous work that shows no impact on fertility. However, it also showed that AE,DC does affect the living arrangements of young women; it permits them to live independently of their families. The conclusion is that level of welfare benef its and acceptance rates and other indicators of availability do not appear to be ashy ciated with sexual activity or pregnancy; however, they may be ascot elated with whether or not a girl who in pregnant decides to abort, mar ry or bear an out-of-wedlock child, and with whom she chooses to live. The evidence is not very strong; more research is needed e The availability of Medicaid and other health care benefits might also affect teen childbearing. In particular, by improving the health of the mother and baby dur ing pregnancy it could reduce the number of miscarriages and increase the number of live births. The availability of Medicaid to cover the cost of an abortion knight increase the number of teens who would opt for abortion over a live birth. However, thin would apply to teens who either already had one child, or those living in families receiving welfare already. The only research on this to date has been conducted on the issue of Medicaid coverage of abortions and teen fertility {Moore, 1980) (see earlier discussion) . Results were inconclusive. Given the lack of effects of AFDC found so far, it is unlikely that Medicaid benefits would be found to bave an impact e ither. Recent leg islation extends Medicaid eligibility to pregnancy if a woman would be eligible at birth. The fact that medical costs are covered may, in fact, encourage a young woman to bear and keep the baby. However, reported time delays in getting on Hedcaid may reduce the likelihood that such coverage will affect childbearing.

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260 SUMMARY AND CONCLUSIONS It is important to caution the reader, first, that it is difficult to show causal relationships between policies or programs and indiviQ~ ual behavior. There are so many other factors, many of which are dis- cussed in earlier chapters, that do affect individual behavior, factors more proximate or immediate in terms of the consequences to the in- dividual. Programs and po.l~cies should not be expected to have large impacts . That some have been found to have impacts and that other s have not is, therefore, of great interest and importance. Programs to Prevent Sexual Activity Sex educa~cion programs appear to be consistently associated with increased knowledge about sex and sexual behavior among participants; however, there is little evidence for a relationship with sexual ac- tiv~ty. In spite of common beliefs, those taking a sex education course do not appear to change their own beliefs and values, although they do become more tolerant of the beliefs and values of others. Parental involvement is more a moral issue than one of conse- quences. That is, even if parental knowledge or communication about the sexual activity of their children were not found to have any rela- tionship at all to their sexual and contraceptive activity, many would still consider it an important issue. There is some evidence that parent-child pros rams do increase communication about sex and birth control between parents and children. The evidence for an impact of communication on their children's behavior is weak. Programs to Prevent Pregnancy There is growing evidence that sex education programs are assay c iated with improved contraceptive use among Those young women who are sexually active. More needs to be known about what aspects of sex edu- cation programs are associated with improved contraceptive use among teenagers. Family planning programs have been frequently and effectively evaluated. As a result, we know a lot about such programs. There is no evidence that the availability of family planning services increases sexual activity among female teenagers; however, it does appear to imp prove contraceptive use and reduce their chances of having an unplanned pregnancy and out-of-wedlock birth. A number of clinic characteristics appear to be associated with attracting teens early in their sexual careers. These are related to outreach and community relations efforts, the convenience of attending the clinic, and the availability of contraceptive services frown phys:- c fans and pharmacies. Most of the same factors also promoted clinic

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261 continuation among those who initiated clinic attendance. Another study found that mean levels of contraceptive use were highest in clinics in which clients expected and stuff employed authoritative guidance in helping the clients to select a contraceptive method. Finally, a third study found client satisfaction with her method to be the best predictor of contraceptive continuation. The only relatively rigorous evaluation of a school-based program is that of the St. Paul MIC project. The evaluation data suggest sub- stantial effects on birth rates in the school (which declined) and sub- stantial effects on post-delivery enrollment among mothers (which in- creased). Neonatal and maternal outcomes do not differ frown national statistics. One available evaluation of a non.school based prevention program (west Dallas Youth Clinic) suggested that the program had been success- ful in reducing teen birthrates. Pregnancy and Pregnancy Resolution For a young woman who is premar itally pregnant, the availability of abortion is associated with a greater probability that she will have an abortion and a lower probability that she will bear a child ou t-of -wed loo k . There are no available evaluations of the recently funded programs directed at increasing adoption as a resolution to teen pregnancy. Given the small incidence of termination of parental rights, such a program is not likely to have a major impact on teen childbearing (Bachrach, 1985; Muraskin, 1984), although more research is needed on this issue. Public school programs for pregnant teens are limited in availa- bility and scope. A complete review and evaluation of these programs was not attempted in this chapter. wIC, a nutritional pros ram for pregnant and parenting women, has been shown to successfully reduce the incidence of low birth weight babies, an impact which is espec tally strong for teenagers. Parenthood Teenage pregnancy programs are directed primarily at pregnant teens and/or teen mothers. Such programs appear to have relatively short term impacts on specific targetted goals. For example, medical prom grams improve infant health: education programs improve educational outcomes; programs emphasizing employment improve employment outcomes. Several types of programs do appear to reduce subsequent childbearing; however, the effects are somewhat weak and may be relatively short-term

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262 on impact. Substantial long-term effects on schooling appear to be robust. Programs for teenage fathers are relatively. new and have not yet been evaluated. An area of great interest is that of the impact of welfare availa- bility and benef it levels on sexual activity and out-of-wedlock child- bear ing . There is little theoretical rationale for expecting an assort elation between welfare benef its and initiating sexual ace ivity, and no evidence exists for an empirical relationship either. However, there is a stronger argument that for solve pregnant teens, welfare may be an attractive option. It may not be a salient option for a middle income girl; however, it may be one for a girl from a low income family. In fact, of the two studies to ask this question, one shows that pregnant girls who are receiving f inancial assistance in the form of welfare are more likely to bear a child out-of-wedlock and less likely to marry or abort. However, since the other study to explore this issue fails to find such a relationship, this association does not appear to be definitive. A third study found, rather, that AFDC does affect living arrangements, increasing the likelihood that a teen mother will live independently. The one study that looked at contra- ceptive use by welfare mothers found that welfare mothers were more likely to use con~craception, less likely to define pregnancies as wanted, and less likely to have a subsequent pregnancy when on than when not on welfare. Unfortunately, these recipients included women of all ages, not just teenagers. Conclusions A variety of types of programs have been reviewed in this chapter. They have been grouped according to their primary focus: prevention of pregnancy versus amelioration of the unfavorable potential outcomes of "early childbearing. Unfortunately, approaches to prevent preg- nancy other than providing contraception (or information about it) are still in the developmental stage. There is no evidence so far that such approaches prevent sexual activity, encourage contraceptive use or prevent pregnancy. In contrast, all the evidence provided over- whelmingly supports the effectiveness of provision of contraception in preventing pregnancy. Whether this be conducted by family planning clinics or private physicians depends in part on characteristics of the individual seeking such services. Clinics are especially impor- tant sources for black and poor teenagers. Recent work has focused on placing the clinics where they can serve teenagers even better--in the schools. The 1 ittle evidence there is ~ one pro ject) does suggest some success in reducing bi rth rates and keeping teens in school. There is no evidence as to whether pregnancies are actually prevented by such school clinics, however. Once pregnant, a number of f actors inf luence the dec is ion as to how to resolve an unplanned pregnancy. The availability of abortion may result in a young woman selecting abortion over either adoption or

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263 bearing an out-of-wedlock child. At the present time the number of young women who terminate their parental rights to a child in the United States seems to be ve ry small. There i. little or no research that looks at the long term nonhealth effects of either abortion on the young woman or on the long term nonhealth effects of giving up a child for adoption on the young woman and her child. Nut r ition programs (TIC, in particular) are effective in improving inf ant outcomes to teen mothers. Finally, there are several models of programs to serve teen mothers that have been implemented and evaluated. Mete evaluations suggest short-term effects in the areas of focus of the program. Substantial long-term effects for all teenagers have yet to be demonstrated; some research folds; Polit et al.) suggests that the most disadvantaged teens may benefit most from such programs. If so, this is somewhat en- couraging news. On the other hand, the McAnarney program illustrates the cliff iculty of reaching the youngest Teens. The evaluations rem viewed do point out the importance of evaluating not just the pros ram as a whole against other programs, but of evaluating specif ic program components. The research so far provides less than adequate informal tion to evaluate what aspects of the programs currently in operation produce what results for what types of young women (and men). As a result, it may be too early to promote particular exemplary program model s. Note 1. Authoritative guidance refers to the nurse, an authority figure either telling The client what birth control method to use or per- suading her to use a particular method.