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. CRAPTER 4 1?E:ENAGE PREGNANCY AND ITS RESOLUTION Sandra L. Bof f erth One major source of confusion in the literature dealing with teen pregnancy and childbearing is precisely the distinction between Nancy and its outcomes. People often say they're referring to teenage preqnanc~ when they only have irlformation on births. Pregnancy can be resolved in a number of ways, only one of which is a live birth kept by the mother. However, in talking about the problems of teen pregnancy, the problems that have been well~documented to date are those associated with that one outcome--bearing and raising a child as a teenager. Another set of confusions revolves around the process which leads ultimately to childbearing and its implications for policy and programs. For example, at agency may be interested in developing profile of young women at risk of teen childbearing to target them for intervention. As discussed in earlier chapters, in order to become a teen mother, a young woman must first become sexually active, next, not use contraception or fail in its use in some way (including experi- encing method failure), and, finally, once pregnant, decide to bear and raise the child her Elf. There are several points at which alterna- tives present tbe~b~.~^ves. Some teens choose one way, others choose another. Thus the agency has several possible points at which to tar- get its interventions: at initiation of sexual activity, at contracep~ tive use, or, at the resolution of a pregnancy. In this chapter some basic demographic description of the number and rates of teen pregnancies, births and abortions are first presented for the United States. Comparisons are drawn with Denmark, a country with registers of health events. Statistics showing the actual way pregnancies to U.S. teens are resolved are presented, followed by a discussion of research that sheds light on the factors associated with resolving a pregnancy one way rather than another. A sundry and conclusions section closes the chapter. BACRGK)UND In 1984 there were 469, 682 births to teenagers 15 to 19, 9, 965 births to teens under 15. This represents a considerable decline in births to teens over the decade, from a high of 656, 000 in 1970. The 78
19 numt er of pregnant ies rose slightly until 1980 and has declined slightly since then. There were over a million pregnancies to teens in 1984 (Table 3.1~. However, the change in the absolute numbers of births and pregnan- c ies does not adequately indicate the incidence of teen pregnancy and childbear ing because it does not take into account changes in the number of teen women. The number of teens rose during the 1970s, leveling off in the mid 1970s and declining since 1979. Nor does it take into consideration the number of women at risk, that is, the number of women who are sexually active (see Hofferth et al., 1986) . This is especially important for teenagers, only a portion of whom are sexually active. Pregnancy retest per 1000 women IS to 19 rose 9 per- cent between 1974 and 1984; however, because the proportion who were sexually active also rose over the per iod, the pregnancy rates per 1000 sexually active women IS to 19 actually fell 8.7 percent between 1974 and 1984. What does this mean for individual women? The pregnancy rate in 1984 was 231 per 1000 sexually active women. mis means that in 1984, 23 percent of sexually active teenagers would have become pregnant. This figure, however, only indicates the proportion of teens who would become pregnant in any one year. A more interesting figure is the pro- portion of young women who would ever become pregnant before reaching age 20. That is, what is the chance that a young woman would become pregnant as a teenager? Although this probability has been estimated using survey data, since abortions are underestimated in such data, the estimates of pregnancy will be low. Better estimates are obtained f ram report ing data such as those collected by the Centers for Disease Con- trol and the Alan Guttmacher Institute. Based on such data it was estimated that in 1981 about 44 percent of young women will become pregnant before reaching age 20, 40 percent of white and 63 percent of black women (Forrest, 1986; Table 3.3~. Of course, this estimate, too, is rather crude, since among those young women are some who became sexually active very early in their teens, others Boo became sexually active very late and others who were still virgins at age 20. The data that are most helpful in showing what the actual risk of pregnancy is among those who are sexually active, breaks the probability down by the length of time since f first intercourse and uses a 1 if e table methodology to estimate the risk of conception within the f irst two years after f irst intercourse (cabin, 1979; Koenig and Zeln~k, 1982~. Data collected in 1976 (Zabin, 1979) indicate that within the f irst three months 9 percent of white and 14 percent of black teenage women will Caere experienced a first premarital pregnancy (Table 3.71. By the end of the first year that figure has risen to 17 percent for whites and 27 percent for blacks, and by the end of two years, 30 percent of whites and 31 percent of black teen- agers will have exper fenced a f irst premar ital pregnancy. Data f rom 1979 (Koenig and Zelnik, 1982) suggest a slight increase in the proba- bility of pregnancy during the first two years after first intercourse between 1976 and 1979, with 33 percent of white teenagers and 43 per- cent of black teenage rs exper ienc ing a f irst premar ital pregnancy with-
80 in two years after first in~cercourse (Table 3.51. me probability of a f irst pregnancy is strongly of fected by two factors--the age at f irst intercourse and the use of contraception (Tables 4. 6 and 4. 8) . Preg- nancy rates are much for those older at f irst intercourse and for those who always used a contraceptive method. mere was little difference in pregnancy between those who used a prescription and non-prescription methods, as long as they always used it (Koenig and Zelnik, 1982) . THE RESOLUTION OF TEEN PREGNANCIES What happens to these one million teenage pregnancies? Many more young women under 20 become pregnant than bear a child, almost twice as many. In 1982 the total births to teenagers 15 to 19 represented 47 percent of the total number of pregnancies (abortions plus births plus miscarr iages [Table 3 .13 ~ . Table 3.2 shows how pregnancies in 1982 were divided: 40 percent of the pregnancies were aborted, and 13 percent miscarried; thus slightly under half, 47 percent, resulted in a live birth. The 47 percent wh ich were live births are divided as follows: 13 percent were postmaritally conceived births, 11 percent were premaritally con- cei~red but born postmaritally, and 23 percent were born out-of~wedlock estimates f ram Table 3.1 and O'Connell and Rogers, 1984) . me resolutions to a premarital pregnancy considered here are abortion versus having a live birth, marriage versus non-marriage, and adoption versus keeping the child . Live Birth versus Abortion The proportion of teenage pregnancies that ended in a live birth decreased over the past decade (Table 3.1~. The number of teen preg- nancies has risen, but because the number of abortions has risen even faster, the number of births has been declining. Both the number of abortions and the abortion rate increased by 50 percent between 1974 and 1980. The percent of teenage pregnancies terminated by abortions cl imbed rapidly, increasing f tom 27 percent to 40 percent between 1974 and 1980. Since 1980, the abortion rate and ratio have rained level. Birth rates for all women have remained fairly level; rates for those sexually active have declined. (Table 3.17. Of course, it is cliff icult to interpret these f igures without some comparison. What is a high level of pregnancy, of births, of abortions for teenagers? Unfortunately, there are only limited international data on abort ions, espec ially by age of the woman. The United States has a high abortion rate for young women compared to western European countries (Jones et al., 1985; Henshaw and O'Reilly, 1983~. The United States also leads in the percent of abortions to teenagers (Tietze, 1983; Bachu, 1983) . In spite of the large number of abortions, births to United States teens are also high, relative to other countries (AGI, 1 981; Jones et al., 1985) .
81 Denmark is a good country with which to compare the United States. Levels of sexual activity among teenagers are actually higher in Den- mark than in the U.S. {Rasmussen and David, 1981~. Abortion laws were liberalized there about the same time as in the United States--the early 1970s. Most important, Denmark has an excellent abortion re- port ing system. With a unique identifying number for each person and a centralized information gathering system, the data on abortion in Denmark are among the most complete in any nation. Pregnancy rates in the United States have been about twice the level of Denmark for the past decade (David et al., 1982 ; Table 3. 1) . In both countries the pregnancy rates increased initially after 1 iberalization of abortion, but levels in Denmark returned to those prior to liberalization, while those in the United States continued to rise. As a result, rates of abortions and births in the U.S. in 1980 and 1981 are considerably higher than in 1970. Abortion rates in both countries rose. However, while they bate leveled off in Denmark, they have continued to rise in the United States. The rapid increase in pregnancy and abortion rates in the U. S. during the 1970s was due to the rapid increase in sexual activity over the same period. Apparently, levels of sexual activity rose dramati- cally in Denmark during the 1960s (Rasmussen and David, 19817; thus by the t ime abort ion was legal ized in both counts ies, sexual activity had begun to level of f in Denmark at a higher level. In contrast, the ma jor increase in sexual activity in the U. S. occurred during the 1970s, with a leveling off during the early 1980s (see discussion, Adapter 1) . As Table 3 . ~ showed, pregnancy rates among those sexually active actually showed a decline between 1974 and 1984. Two valuable lessons f ram these data and f ram a recent study of five western European nations fJones et al., 1986) are that 1) high levels of sexual activity do not necessar fly result in high pregnancy rates, given adequate use of contraception, and 2) low birth rates do not necessarily imply high abortion rates: they may simply imply low pregnancy rates. Low abortion rates and low birth rates are com- patible. Among teens, the proport ion of pregnancies terminated by abortion is higher in Denmark than in the United States, primarily due to the high abortion ratio among 15 to 17 year old Danes (David et al., 1982) . 15 to 17 year old United States teens are much more likely to bear their babies than Danish 15 to 17 year olds. Jones et al. (1985) also found that in each of S developed nations they investigated, that 15-17 year olds were much more likely to abort a pregnancy than 18-19 year olds: the d if ference was smallest in the U .S . ~ is suggests substan- tial dif ferences between United States and other countries in choice of resolution for unplanned pregnancies, differences which will be pursued a little later. Mar riage One way of resolving an out-of-wedlock teenage pregnancy is by marrying. So far all teenage pregnancies have been lumped together.
82 In fact, some 13 percent of all teenage births are post~ritally con- ceived (Table 3.2), and such births are not generally considered to be problematic. In 1980 only 5 percent of abortions to teens 15 to 19 (about 2 percent of all pregnancies) were to married women (Henshaw et al., 198S) . Assuming that abortions indicate that a pregnancy was un- intended, it can be inferred that most pregnancies to married women are intended. Zelnik (1979) found that 53 percent of first births to women who were married were unintended. If to the proportion of postmarital births are added a proportion of the miscarriages and a small propor- tion of the abortions, it can be seen that that between IS and 20 per- cent of all pregnancies to women under 20 occur to married women. me remainder, 80 to 85 percent, are premarital pregnancies. Earlier, it was pointed out that about 24 percent of sexually active teenagers age 14 become pregnant each year. Bowever, this does not tel.] us bow many teenagers age 14 become pregnant before they reach ~0 or marry. According to 1979 survey data (Zeln~k and Kantner, lB80), 16 percent of all metro teenage women 15 to 19 had ever experienced a premarital pregnancy, double that of 1971. Of those sexually active, 33 percent had ever experienced a premarital pregnancy, a small ~n- crease since 1971. Thus, when control is introduced for the increase in sexual activity over the decade of the 1970's, the incidence of pre- marital pregnancy has not changed very much. The major reason for the large apparent increase in premarital pregnancy is the increase in sexual activity. There was an increase in premarital pregnancy among sexually act ive wh ite teens, but not among black teens. The lack of increase among blacks is probably due to underreporting of abortion. Thus premarital pregnancy has increased, but not as much among those sexually active as it appears from the increase in the population of teenagers. Data from the 1982 National Survey of Family Growth show a slight decline in premarital pregnancy among teenagers between 1979 and 1982, although the difference is probably not statistically sig- nificant. In 1982 14 percent of all teen women 15 to 19 had ever experienced a premarital pregnancy, compared with 16 percent in 1979. Of those premaritally sexually active, 30 percent experienced a pre- marital pregnancy. These figures substantially underestimate the true proportion of teenagers who become pregnant before they reach age 20 or marry because abortions are substantially underreported in surveys--by as much as SO percent. Some subgroups report more accurately than other subgroups (Mosber, 19851. Ur~arried black teenage females are the least likely to accurately report their abortions, with unmarr fed white teenage females only slightly more accurate. Older married white females are the most accurate reporters of their own abortions. Since accurate pregnancy estimates depend on accurate abortion reports, the reports of pregnancy obtained from surveys will be lower than those estimated on the basis of nationally collected data from organizations such as the Centers for Disease Control and the Alan Guttmacher Institute. Recent calculations f rom the latter (Forrest, 1986; Table 3.3) suggest that based on 1981 data about 40 percent of white teenagers 15-19 and 63 percent of black teenagers would experience a first pregnancy before reaching age 20.
83 The increase in premarital pregnancy over the decade of the 1970s was not due to an increased wontedness of pregnancy. Table 3.6 shows that the proportion of premaritally pregnant teens who were unmarried at resolution who wanted the pregnancy actually declined between 1971 and 1979 for whites and blacks alike, and the proportion using contra- ception increased (Zelnik and Rantner, 1980; Table 4.43. Of course, premaritally conceived but marital births, which constitute about 11 percent of teen pregnancies, are excluded here. Bowe~rer, since the proportion who marry to resolve a premarital pregnancy also declined, the proportion who wanted a pregnancy probably also declined for all premar itally pregnant teen women. Contraceptive use generally improved between 1971 and 1982. A smaller proportion reported never using contraception, a higher prom portion reported always using it. A larger proportion used contra- ception at f irst intercourse and at last intercourse in 1982 than in 1971. Unfortunately, Table 3 .4 shows that the percentage of pre- mar~tally sexually active teen women who ever experienced a premarital first pregnancy rose in all contraceptive use statuses 1976-79, except for those trio used contraception at first intercourse but not always (Zelnik and Panther, 1980~. The largest increase was among never users, but increases also occurred among those who always used contra- ception. The authors attribute this increase in pregnancy, parti- cularly among the youngest teens, to sharply increased frequency of intercourse and to decreased reliance on the most Of fective methods of contraception (Koenig and Zelnik, 1982) . Data are not yet available f rom the 1982 NSFG to see whether pregnancy rates continued to increase among contraceptive users as well as non-users. We suspect they have not, s ince pregnancy rates have been declining . Adopt ion Data f rom three surveys of young women (Bachrach, 1985) show that the proportion of teenage women whose f irst pregnancy ended in a f irst premarital birth and who gave their baby up for adoption declined in the 197 Os between 19 71 and 1976 and leveled of f at a low level between 1976 and 1982 (Table 8.1~. Eighteen percent of white teenagers rem ported having terminated parental rights in 1971, 2 percent of blacks. By 1916 only 7.0 of whites and no blacks reported having given up a baby for adoption. By 1982 7.4 percent of whites and fewer than 1 per- cent of blacks reported having 9 ices up a child for adoption. Based on data from the National Survey of Family Growth, the estimated annual number of unrelated adoptions declined to a low in 1976 and has been gradually increasing since then. Agency data support survey evidence wd ice showed declining adoption placements f rom the early to the mid-1970s {Bachracb, 198S) . Legal abort ion became an alternative to adoption for many young women who had an unintended pregnancy and who would have adopted if abortion were not available. It has been argued that the reduced social stigma attached to unwed pregnancy caused a shift away f ram adoption as an alternative
84 to childbirth. me subsequent apparent increase in adoption may be a response to the substantial demand for babies to adopt as well as a re- sponse to the many concerns about the ethics of abortion. This is just speculation, since there is no research that would allow us to shed light on these changes. Just documenting the changes that have occur- red is a cliff icult task. RESEA=E Factors Associated with Resolution of Premarital Teen Pregnancies: Delivering the Baby Once a teenager is pregnant, what factors are associated with whether she has an abortion or carries the pregnancy to term and de- livers the baby? One study found that the younger the teen at concep- tion, the more likely she was to carry the pregnancy to term (Zelnik et al., 19811. In this study 13 to 16 year aids were more likely to have a live b~rtb compared with 17 to 19 year olds comparable on other factors. This is supported by data from another study, which found that of those ,3 to 19, the 16 to 17 year aids were most likely to have a live birth. However, national statistics on abortion ratios do not support these findings. The true explanation may be the underreporting of abortions in sample surveys of teenagers, which i`; likely to be most serious for the younger teens. An underreporting of abortions would increase the apparent proportion who carry pregnancies to term. Thus, due to underreporting of abortion, it is not clear whether factors are related to choice of abortion or birth or to whether abortion is re- ported. This is a serious problem for analytic study of abortion using sample surveys. The bi rth year of the teenager is important. At a, g iven age, ear lier birth cohorts are more likely than more recent cohorts to have a live birth (Zelnik et al., 1981) . Young women are more likely than in the past to resolve a premari- tal pregnancy by abortion (Table 4.51. White teenagers were 1.3 times and black teenagers 2.5 times more likely to have an induced abortion In 1978 than in 1972. Although in the early 1970s black teenagers had a lower likelihood of using abortion to resolve pregnancy, according to these abortion ratios, after 1974 the abortion ratios are similar or slightly higher for blacks than whites. Since abortion data appear to be underreported more for blacks (Zelnik and Kantner, 1980), the difference in levels between blacks and whites may be underestimated. The abortion ratio appears to have levelled off after 1980, according to national figures {Table 3.1~. The black~white difference in likelihood of abortion varies by age. Among young teenagers the ratio of abortions to births is lower for blacks than whites {Table 4. 6) . However, this difference decliner such that ratios are simile r for 19 year olds. Among older women, ratios are h igher for blacks than for whites.
85 One source of difference is the age at which abortions and preg- nancies are measured. The Ezzard et al. (1982) study (Table 4.S) adjusted age to age at conception. This is particularly important at younger ages. Only a third of women who became pregnant before age 15 were still under 15 at delivery, while three-fourths of those obtaining abortion were still under 15 at the time of abortion (Henshaw et al., 1985} . Thus differences between the f igures will be sharpest at youngest ages. Zelnik et al. {1981) found that the more religious a young women, the snore likely she is, once pregnant, to bear the child. Another study using data from a small study of health providers in Ventura County California found white Catholics to be less likely to have a live birth, once pregnant than either white non~atholics or Hispanic Catholics (Eisen et al., 1983) . Thus the particular religious affili- ation appears less important in the decision than the strength of religious conviction. Teens living in the East or North central United States or in an urban area are more likely to have a live birth, once pregnant, than those in other regions or in non-urban areas (Zelnik et al., 1980~. The most important family factor associated with delivering a baby versus aborting a pregnancy is parental education. The higher the education of parents, the lower the likelihood that ~ teenager, once pregnant, will have a live birth (Zelnik et al., 1980) . The mother's opinion of abortion is important, with girls whose mothers are more favorably disposed toward abortion less likely to have a live birth (Eisen et al., 1983) . Peer environment is important. The more positive a likely a young pregnant girl is to have a live birth (Eisen et al., 19831. In addi- tion, g iris who know a single teen mother are more likely to have a live birth (Eisen et al., 1983) . Among the most important factors affecting the outcome of the preg- nancy was whether the pregnancy was wanted. Girls who said they wanted the pregnancy were much more 1 ikely to have a live birth than those who didn't (Zeinik et al., 19801. Of course, this measure of wontedness was obtained after the resolution of the pregnancy; ex-post facto rationalization may be measured here. Beliefs about abortion and birth are important. Baving favorable attitudes toward and beliefs about abortion prior to the event were assoc iated with a lower probability of having a live birth (Eisen et al., 1983) and with a positive abortion intention (Smetana and Adler, 19797. Intention to have an abortion was associated with a lower probability of having a live birth {Smetana and Adler, 1979)e Positive bel ief s about having a child were assoc fated with a low intention to have an abortion. Finally, women choosing either abortion or birth be- 1 ieved others wanted them to follow this alternative, with women intending abortion most motivated to comply with friends' expectations (Smetana and Adler, 19791.
86 Among the most important factors associated with choice of preg- nancy resolution are expectations and academic achievement. High school dropouts and those not enrolled in school, those with a low grade point average, and those with low educational expectations have been found more likely, once pregnant, to bare a live birth (Eisen et al., 1983; Leibowitz et al., 1980; Devaney and Ilubley, 1981~. Two studies have looked at the relationship between receipt of AFDC and pregnancy resolution decision. Moore and Caldwell looked at the probability of abortion, marriage and out-of~wedlock birth among premaritally pregnant U.S. women aged 15 to 19 in 1971, data collected by Rantner and Zelnik in the National Survey of Young Women. Gontrol- ling for a number of individual characteristics, such as education of the father, wantedness of pregnancy, importance of religion and race, they found the probability of abortion to be significantly lower in states having relatively generous AFDC benefit levels (Moore and Caldwel1, 1977} . E isen et al . ( 1983 ~ and Leibowitz et al. ( 1980 ~ examined a 9 coup of 299 pregnant teenagers who went to health providers in Ventura County, California between 1972 and 1974 for assistance in terminating a pregnancy or for prenatal care. Me teens were interviewed twice, once prior to abort ion or delivery and a second time six months at ter the resolution of the pregnancy. The authors hypothesized that young women who received state support would be more likely to choose do livery than girls who were self-supporting. They found that both receiving f inancial aid f roan the family and receiving f inancial aid from the state {AFOC) were associated with choosing delivery Hisser et al., 1983; Leibowitz et al., 1980~. However, more young women than those currently living in welfare families would be eligible for wel- fare if they did g lure birth; thus the study really measures the ef feet of actual receipt of welfare benef its, rather than their availabil ity. Factors Associated with Marriage Before Birth (I`egitimation) Young women are less likely now than in the past to resolve a pre- marital pregnancy by marrying. The proportion of women pregnant before marriage To resolved a premarital pregnancy by marrying dropped by 50 percent between 1971 and 1979 for both whites and blacks {2elnik and Fantner, 19801. me data show very little additional change between 1979 and 1982, although the data are not completely comparable, and the total number of pregnancies is underreported (Born, 1985~. If we look only at pregnancies that end in a live birth, we see that of the total first births to white and black teenagers, the prom portion conceived outside of marriage has risen, and the proportion pre~naritally conceived but legitimated before birth ro';e then declined to about the same initial level (O'Connell and Rogers, 1985) . As a result, the proportion born out of wedlock rose sharply. Two studies have examined factors associated with Abetter a prep maritally pregnant teenager who subsequently had a birth married prior
87 to that birth: Zeinik et al. (1981) used date from the National Survey of Young Women in 1971 and 1976. They found that (among those who were premaritally pregnant and gave birth) white teenagers, those from a higher socioeconomic status background and those who wanted the baby were more likely to marry before bearing the child. me second study used the data from venture County, California (Eisen et al., 19837. mey fauna that (among those who carried To term) the only factor that discriminated between those who married before the birth and those who didn' t was whether the family had been receiving f inancial aid f rom the state. Those girls whose familice had been receiving financial aid from the state during pregnancy were less likely to Wary than those who had not been receiving such assistance (Eisen et al., 1983~. Factors Associated with Bearing an Out-of-Wedlock mild The resolution many people are interested in is that of bearing a child out-of~edlock compared with all other options. me previous analyses bare explored the decisions in temporal sequence: that is, they have looked at, first, the decision to abort or carry a premarital pregnancy to term, and, second, the decision to marry or not marry before birth among those who carry to term. Several analyses have studied this decision as a joint one with three choices: 1) abortion, 2) marriage and birth, and 3) bearing an out-of~ediock child. me results of studies viewing the decision this way do not differ from the results of studies using paired comparisons only, but this approach allows simultaneous comparison among all alternative resolutions. Young women who are black, who live in ~ metropolitan area, whose parents are of low educational levels, who are young at first concept tion, and who live in a large family are more likely to bear a child out-of-wedlock than to either abort or marry (Eisen et al., 1983; Leibowitz et al., 1980 ; Deveney and Hubley, 1981 ; Zelnik et al., 1980) . In addition, Leibowitz et al., 1980 and Eisen et al., 1983 found teens living in families receiving financial aid from the state to be more likely than their peers to bear an out-of-wedlock child. In contrast, using 1971 data from the National Survey of Young Women, Hoore and Caldwell (1977) found no relationship between level of ~DC benefits and having an out-of~wedlock birth. me latter found a negative rela- tionabip between AFDC acceptance rates and the probability of having an out-of~wedlock birth. =at is, young women in states with high acceptance rates were less likely to have an out-of-wedlock birth (Moore and Caldwell, 19773. mere was no significant association be- tween AFOC benefit levels and acceptance rates and the probability of marrying before ehe birth (Hove and Caldwell, 19773. Adopt ion Only a few studies have compared teens who have made adoption plans with teens who beve kept and parented their children. These ape swim marized in Resnick (1984~. The results suggest thee teenagers who make adopt son plans are similar to those who have abortions but different f ram those who take on parenting responsibilities. me former tend to
88 be older, to have wore parental influence and less male partner influ- ence, anti to be of higher socioeconomic status. Parenting teens tend to be younger, to beve less schooling, to not be attending school and to come from non-intact homes. Thus those who make adoption plans tend to have more prospects for the future. In addition, they were reared in smaller towns and cities and have more traditional attitudes about abortion and family life (Resnick, 19841. Recent data from the 1982 National Survey of Family Growth (Bach- rach, 1985) show that teenagers under 18, whose parents have had some college, whose baby was born before 1973, and who were living with both parents at age 14 were more likely than other teenagers to place the child for adoption if they had a premarital birth. Two recent studies {Rallen, 1984; Resnick, 1984) are funded by the Office of Adolescent Pregnancy Programs tO look more closely at the factors affecting the decision of unmarried pregnant teens to make an adoption plan. At this writing no results are yet available. Factor. Associated winch Decision Satisfaction It is obvious that no one decision is the ~right. decision for all adolescents, since the circumstances differ among individuals. Bow- ever, researcbers have found some regularities in the extent to which individuals express satisfaction or dissatisfaction about the decisions they bare made in resolving their pregnant ies. A study of a Danish sample found that the degree of satisfaction with the decision depended on the f irmness of the decision in the f irst place. Of those who had made a firm decision to abort soon after learning about pregnancy, 94 percent said that the decision was correct 6 months later. Of those who were not so certain, 72 percent said that the decision was correct 6 months later (David et al., 19827. Of those whose decision was firm, 59 percent experienced relief afterward, compared with 28 percent of the less firm. None of the Danish women expressed feeling of guilt over the decision. A study of United States teen women (Rosen, 1983) found that the more alternatives considered, the greater the dissatisfaction with the decision. This probably reflects greater uncertainty as to what to do, and is conststent results from the Danish study {David et al., 1982) . The Eisen and Bellman ( 1984) study of pregnant teens in Ventura Coun~cy, California found no significant difference in decision satis- faction 6 months after pregnancy resolution by type of decision made, age or ethnic group. Nearly all--80 percent--acpressed satisfaction in their decision. There were son e differences in degree of satisfac- tion depending on the decision made. Among teenagers who chose abor- tion, those with better educated mothers, who had advocated abortion for themselves, who were more approving of abortion in general and who used contraception more consistently following abortion were more satisfied (Eisen and Bellman, 1984~. Among teens who chose single motherhood, those not enrolled in formal sebooling dur ing the six
89 months after birth were more likely to be satisfied with the decision, as were those with maternal support for single parent Status. Among teens who married, none of the variables utilized significantly dif- ferentiated those who were satisfied with their decision from those who weren' t. Interest ing and Controversial Issues Tree issues are worth looking at further. The f irst issue is the relationship between age and pregnancy resolut ion. Young teenagers in the United States have a very high probability of bearing the child, once pregnant, compared to older teenagers or teenagers in other coun- tries (Jones et al., 1985) . Data f ram the Danish study (David et al., 1982) show abortion ratios (abortions divided by births plus abortions) to lS to 17 year aids that are twice those of U.S. lS-17 year olds. Three-quarter of the pregnancies to young Danish teens are terminated by abortion, compared with 40 percent of those to young U.S. teens. Abortion ratios for 18 to l9 year aids are very similar in the U.S. and in Denmark. Results f ram the National Survey of Young women sug- gested ~chat, net of other factors, girls younger at conception are more likely than older teens to carry a pregnancy to term. Although the differences are exaggerated because of the underreporting of abortion at younger ages, it could be expected that abortion would be higher at younger ages than at older ages, as shown by the Danish sample, since few young women wanted these pregnancies. Thus the lack of difference by age in the United States is of in- terest. Why are IS to 17 year old pregnant teens in the United States so much more 1 ikely to bear ~ child than comparable teen. in ~ country such as Denmark and other countries? Why are they as likely to bear a child as their 18 to 19 year old peers in the V.S.? The second important issue is that of race differences in pregnancy resolution. The chapter has emphasized dif ferences between blacks and whites, but conclusion. about race differences in pregnancy resolution based on analyses of surrey data are of necessity weak because of dif- ferential reporting of abortion by race in those data sets. Me best information on subgroup characteristics come from the Centers for Disease Control, AGI, and from the National Center for Health Statis- tics and they are good. However, such data do not provide the depth of information needed to explore causal factors in decision-making. Another problem is whether to use abortion rates or ratios. The abor- tion ratio is higher among blacks than whites for all ages except the teen years (Table 4.6~. During the teen years, the ratio of induced terminations of pregnancy to live births is higher for whites than for blacks. However, if you look at the abortion rate {Table 4.4) the rate Is bigher for nonwhites than for whites at all ages. This is because the pregnancy rate for nonwhites is also higher. Thus, in this case, using the abortion rate would lead to a completely different and erroneous conclusion about black~white differences. Analysts need to choose the appropriate measure for their purposes.
so One reason for the differences between blacks and whites in abor- tion is that blacks appear to use abortion for spacing or to end child- bearing more than to postpone a first Dearth. Sixty-five percent of abortions to whites occurred to childless women, compared to 39 percent of abortions to blacks (Table 4. 7) . However, there is another problem with the data. Figures are often based on age of the woman at pregnancy outcome. Since birth occurs nine months and abortion approximately 3 months after a conception, a proportion of the young women who conceived (and who eventually bore a child} at the sane time as those who conceived and who eventually ter- minated the pregnancy through abortion would be one year older at out- come. Thus the event (pregnancy) occurred at the same age, but this would not be reflected in the statistics. Adjusting the data to age at conception would take care of this problem, but would also alter the number of births and abortions, especially at younger ages. Emus the Ezzard et al. (1982) study (Table 4. 5) shows almost no black~white difference in abortion ratios when abortions and births are adjusted to age at conception. Th is raises an important issue of comparability of measures across studies. me Alan Guttmacher Institute has moved toward reporting ratios adjusted to age at conception. The other organizations that report abortion statistics do not yet do so {the Center. s for Disease Control and the National Center for Health S Eat ist ics) . A third interesting issue is that of repeat abortion. In 1980 one~third of U.S. aborters had previously had an abortion (Tietze, 1978; Henshaw and O'Reilly, 1983: Table 7) . The f igure is smaller for teenagers, as could be expected, since they have not had as much time to bare one, let alone two abortions. NCES data suggest that 12 per- cent of abortions to 15 to 17 year olds, and 22 percent of abortions to 18 to 19 year olds are repeat abortions (Table 4.71. There are two potential reasons for concern. First, there may be negative effects of abort ion on later childbear ing and subsequent pregnant ies . Second, there may be (o~rer~utilization of abortion as substitute for contraceE~ tion. Are there negative effects of abortion on later childbearing and subsequent pregnancies? This literature has been reviewed An Strobino (in this volume) and Bogue (19821; the reader is referred to those sources. After adjusting for the fact that abortions performed on teenagers are performed later in pregnancy, wh ich is somewhat more risky, rates of mortality and morbidity from abortion are somewhat lower for teenagers than for adult women. There is only one instance in which teenagers appeared to be at higher risk of injury then adults. Teenagers appeared to be at higher risk of cervical damage than older women {Cates et al., 1983; Cates, 1981~. Although there is little --'idence that having had one prior abor- tion increases a woman's ris;. of miscarriage, premature ~ Ether bear ing a low birth weight baDy, there is some evidence that having had multiple abortions may increase this risk, although. again, the results of several different studies do not agree (Levin et al., 1980; Chung et al., 1982) .
91 Is abortion overutilized as a substitute for contraception? Me concern that abortion is becoming a substitute for contraception does not seem founded. Although in 1971 ache percentage of teen women who bed a premarital second pregnancy was higher 2 years after the outcome of the first premarital pregnancy for those who had an abortion than for those who had a birth, by 1979 the f igures were reversed. In 1979 teen women who had Terminated their premarital first pregnancy by abor- tion were less likely to have a second pregnancy within two years than those who had carried the first pregnancy to term (Koenig and 2elnik, 19821. Tietze {1978) argued that the increasing number of repeat abortions reflects the increasing number of women who have had a first abortion and are, therefore, at risk of having a second abortion. This appears to be born out by a recent study that shows few differences between women obtaining a f irst and those obtaining a repeat abortion (Berger et al., 19841. pose obtaining a repeat abortion were older, less likely to be married and more tolerant of legal abortion than were women baying a first abortion. hey had intercourse more frequently and they were more likely to have been contracepting when they became pregnant. They did not differ on type of method used or on any other demographic, psychological or attitudinal measures. Finally, results from a 1982 national survey show that fewer than one half of 1 percent of women exposed to the risk of unintended pregnancy, who did not use contraception, mentioned the availlability of abortion as a reason for nonuse (Forrest and Henshaw, 1983~. SUMMARY AND CONCLUSIONS How women choose to resolve their pregnancies teas become one of the ma jor factors determining the number and rate of births to teens. Only about half of all pregnancies to teens end in a live birth. Yet only a very small amount of research has been conducted on this important issue. One important issue that researchers have just begun to address is whether miscarriage and abortion have psychological, social, health, familial, educational, economic or other consequences for adolescents and for their families. A few studies have focused on short term psycholog ical ef feats, but there are no long term studies. The many studies of health effects that have been conducted have found little negative impact on health (Hogue en al., l982~. One major question that several researchers have addressed is why individual women choose one form of resolution to a pregnancy over anothere me major studies in this area use two data sets: the National Surveys of Young Women {1971, 76, 79) and a study of 299 women in Venture County, California in 1972-74. mese are the only studies to provide ~nulti~rariate stridence on the issue, and they are the only studies to have focused on the resolution of premarital teen pregnancies (as distinguished from postmarital teen pregnancies. In is important to make this distinction. Few people consider maritally conceived pregnancies problematic, although, among young teenagers, they may be. Research suggests that a premar~tally pregnant teen is ore likely to give birth rather than obtain an abortion if she wanted the pregnancy, is of lower sac ioeconomic status, Is unfavorably dis-
92 posed to abortion, has lower aspirations and educational expectations, receives parental financial assistance, currently lives in a family that receives public assistance, and lives in a state with higher AFDC benefit levels. Ite~e results.are based on a very limited set of studies, however, and all these studies suffer from underreporting of abortion. Among those who give birth, those who are of lower socioeconomic status, who are younger, and who are black are less likely to marry than their peer.. Two types of data are needed: 1) Vital statistics data that can provide national estimates of abortion (and, as a result, pregnancies) by age and, simultaneously, by race/ethnicity, and 2) Survey data that not only provide reasonable estates of abortion but also contain vat iables that could be used to test hypotbeses about relet ionships among variables both at one point and over time. At the present time there are no national reporting requirements for abortions. Abortion data are presently esti~ted from three sources: a national survey of providers by the Alan Guttmacher Institute, counts of characteristics of abortion patients obtained by the Centers for Disease Control and counts of abort ions obtained in 12-13 reporting states by the National Center for Bealth Statistics. National estates of abortions in sur- vey data can be obta ined f rom the Nat ionize ~ Audrey of Young Women ~ 1911, 1976} and the National Survey of You rag Women; and Young Men (1979}, the National Survey of doily Growth, Cycle II: ~ 1982), and the National I`ongitudinal Survey of Youth, Ohio State University {1979-19851. Un- fortunately, all these surveys bave documented substantial under- reporting of abortions, so they should be used cautiously until we have a better understanding of the bias this introduce. into our analyses. Note 1 Pregnancies ~ Births and abortions plus miscarriages. Accurate abortion cats are needed to calculate the number of pregnancies. Abortion we. legalized in the U.S. in 1973. Prior to this year, the annual number of abortions in the U.S. could only be estimated. Therefore, 1974 was Selected as a comparison year since it.is probably the first full year with good abortion statistics.
