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1 Introcluction Adolescent pregnancy is widely recognized as a complex and serious problem in Amenca. Why it is a problem, however, and what can or ought to be done to solve it are matters of dispute among individuals and groups with conflicting values, viewpoints, and agendas. Adolescent pregnancy and childbeanng are not new phenomena In the United States. Nor are they charactenst~c of most teenagers, as some accounts in the mass media suggest. Nevertheless, the simultaneous emer- gence of several social and demographic changes have made these issues more visible over the past two decades. Levels of sexual activity and pregnancy increased dramatically dunng the 1970s among an expanding population of unmarried teenagers. Al- though these rates have declined slightly since their peak In the late 1970s, a significantly greater proportion of adolescents is sexually active and expenenaDg Contended pregnancy am the m:~-1980s than In 1971 (Zeinik and Kanmer, 1980; Pratt and Hendershot, 1984~. Today approximately 45 percent of girls ages 1~19 are sexually active before marnage, and an estimated 36 percent of them become pregnant within two years of initiation of sexual activity (Zeinik and Shah, 1983; Koenig and Ze~ik, 1982). Not every pregnancy, however, results in a both. The growing rate of abortion since 1973 has caused a reauci~on In the rate of childbearing among women undoer age 20. Nearly 40 percent of all teenage pregnancies are voluntarily terminate. Nevertheless, nearly 470,000 infants are born each year to mothers who have not yet reached their twentieth birthday; more than a third of them are born to women Dyer 18 Cations Center 15

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16 ADOLESCENT SEXUALITY; PREGNANCY AND CHILDBEARING for Health Statistics, 1984b; see also Vol. Il). It is striking to note that despite declining fertility rates since i970, rates of a~o~esceIlt Begs r, abortion, and childbeanng have remame] considerably higher ~ the United States than in the majority of other developed couches with comparable levels of early sexual acuity. The contrast is especially ~a- mane for gins under 15. Among these young adolescents, the U.S. rate, at fi~reb~hs per 1,000 girls of comparable age, is 'four times greater than that of Canada, the only other counts th as many as one birth per i,000 Ads (Akin Guttmacher Suture, ~ press). There are similar pattems for pregnancies and abortions. Though proportionately fewer U.S. teenagers are hailing babies, a growing percentage of all teenage births over the past 15 years have occurred outside marriage (Nanonal Center for Health Statistics, 1984b; see also Vol. Il)- HaKthe adolescents who carry their pregnancies to terse are unmarried at the time of both, compared with approximately 15 percent who gave both outside marriage In 1960 (Bureau of the Census, 1984b). Among those who are married at the birth of their child or shortly thereafter, many divorce or separate while the child is stiD very young. A majonty of teenage families with children are sings - parent families, and an overwhelming proportion of them are poor. THE NATURE OF 1~ PROBLEM The problem of adolescent pregnancy and childbearing involves issues Cat are intensely debated and that raise a number of fimdamental political, moral, and policy concerns. Some view the problem as early, nonmarital sexual aciinty: if teenagers were not engaging in se:mal intercourse, they would not become preg- n~t. Adolescent sexual act:~nty, many would argue, regardless of the extent to which it resects broader somal trends, represents a decline ~ tray one] family values. In addition, it affords exposure to seamy transmitted diseases and may pose additional undocumented psychologi- cal nsks. Hence, many regard early se:mal intercourse as the primary problem whether or not * results in pregnancy. According to this new, policies and programs that acknowledge sexual activity outside marriage are believed to undermine parental authority, to legiinnize fimdamentally immoral behavior, and probably to encourage teenagers to engage in sexual intercourse at younger ages. Advocates of this new hold that parents should have authonty and responsibility for their minor (under

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IN7:RODUCUON 1 7 age 18) children's sexual involvement. Sex education and counseling, contraceptive decision making, and pregnancy resolution, they believe, should be managed withy the family and should not be matters of public policy. Others, however, argue that changing patterns of teenage sexual be- hanor are the inevitable consequence of broader social trends, including adult seal liberalization, the widespread use of contraception, fem:- nism, changing family fonns and patterns of marriage, and changing education and work patterns. Once norms of adult se:ma1 behavior change, many believe It is unrealistic tO think these norms ~ not also be adopted by young people. Public policy and programs, they suggest, should be directed at mmimi=ng the personal and societal risks associated with early sexual activity and at helping teenagers become responsible for their actions. Many adolescents have a difficult time discussing sex with their parents, and mmy parents find it Uncut to help they adolescent children understand and avoid the risk of pregnancy. Accordingly, advo- cates ofthis view believe that public programs should help teenagers guard against unintended pregnancy and should protect their confidentiality In the process. Moreover, the COStS of preventing pregnancy, they contend, are far less than the COStS of ameliorating the likely negative social, eco- nom~c, and health consequences of early childbeanng. She others believe abo*ionis the problem. Voluntary~crmmanon of an ~ ninteIlded pregnancy is regarded by many as inhumane and immoral regardless of the mother's age. Despite the legalizanon of abortion, debate continues among smeIliists, philosophers' theologians, aids lay people about when life beds and when the intentional 3~terrupu0n of a preg- Nancy constitutes the unethical destruction of life. As medical technology increases the prospects of a normal life for many preterm infants, the issue becomes more biscuit. Others, however, acme that the legalization of abortion ensures the Mental right of ad women, regardless of age, to autonomy in mat- ters of procreation. Whether or not to continue a pregnancy, they mam- tam, is a decision for each woman to make in consultation with her physician. Law and public opinion differ on how much parent mvolve- ment should be required ~ abortion decisions by minors. Some states require either consent by parents or judicial determ~nanon. Nevertheless, many people- believe that public policy should be aimed at malting legal, safe, an] pro~essiona~y pronded abortion services available to teenage g~risw~thout restriction. Appropnate counseling, they suggest, should tee

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18 Al)OLESCENT SEXUALITY PREGNANCY AND CHILDBEARING provided to help young women make responsible decisions conceming the resolution of an unintended pregnancy and to minimize the emotional straw. Counselors shows encourage adolescents to Evolve they parents and their partners in the dec~sion-:nak~g process. Yet in circumstances In which a young woman is judged by health professionals to be mature arid is Table or unwilling to consult her parents, proponents of this new believe she should be able to decide whether to terminate her pregnancy without parental consent or knowledge. Still others in our somety view the most competing problem as neither early sexual activity nor abortion, but as teenage childbeanng. Adolescent mothers are significantly more likely to curtail their education, to be relegated to low-paying jobs, to be single parents, and to be on welfare than are women who delay childbearing until their ~enties. Teenagers who become fathers and assume parenting roles are significantly more likely tO mop Out of school and to be unemployed. Teenage marriages are more likely than those of older couples to end ~ separation and divorce. And for many young women, marriage is not a viable option. Adolescent childbearing makes economic success more difficult and further climin- ishes the opportunities of poor and minority your3g people who can ill adore the compounded hardships. In addition, the chicken of teenage parents are especially vulnerable to health and cognitive problems, aIld they are at greater risk of expenencing an early pregnancy and birth themselves. Many believe that the COStS of early childbearing, both to mdividn~lc and to surety, are too high. This group maintains that pre~ren- tion of adolescent pregnancy should be the highest pnonty. Nevertheless, those situations in which contraception fails and abortion is not an acceptable course, some advocate adoption as an alternative to early par- enthood. Others urge the provision of special supports and services to ensure healthy outcomes for young mothers and their chil~en and to promote long-term economic autonomy for young families. THE SEARCH FOR SOI~UTIONS The widespread moral and political disagreement about why adolescent pregnancy Is a problem has created cohesion and conflict over what to do about it. Political, educational, and religious leaders, as well as parents of teenagers, appear dinded over what their primary goals should be: to discourage or delay sexual intercourse among young, untied m~iv~- uals; to reduce teenage pregnancies through the promotion of education,

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INTRODUCTION 19 counseling, and contraceptive services; to ensure the availability and acces- sibility of abortion; to facilitate adoption; or to diminish the negative social, econorn~c, and health consequences associated with early childbear- ing by the provision of special income and ~n-kind supports to pregnant and parenting teenagers. In the United States dunug the past two decades, there has been no coherent policy toward adolescent pregnancy and childbeanug. American teenagers receive conflicting messages about sexuality, sexual behavior, and sexual responsibility. As a recent Alan Guttmacher Institute study fin press) suggests, teenagers' exposure to sex through the popular media tells them that sex is exciting and romantic. Premantal sex, cohabitation, and nonmantai relationships are common ways of life among the adults they see and hear about, often including their own parents or the parents of their peers. Yet they receive little open and informed Alice about se~al- ity, contraception, or the harsh realities of early pregnancy and parenting. What they are told iS that good Uris say no (~= Gut~acher Institute, press). Such confused messages inevitably result from the striking ambiva- lence about sex ~ our society. In tU=, these mixed messages may contnb- ute to the commun~cai~on problems of many adolescents and thereby enhance the risks of early pregnancy, births outside marriage, and abor tion. The fact that adolescents are not a monolithic group aDd that adolescent pregnancy is not a unitary problem adds to the complexly, of the issue. For young people of different ages, living in different social, economic, and cultural circumstances, the sigliificaDce of early sexual activity, pregnancy, and childbeanng is not the same. The values, is, and expectations influencing their attitudes and behavior vary sharply. Young people who are poor do not have the same opportunities and expenences as those from more advantaged backgrounds. Moreover, most 14-year-olds are not the same as most 18- or 19-year-olds. Their levels of social, emotional, and cognitive development are Indifferent Their abilities to establish life goals, to appraise oppo~iities, and to assess risks are different. Their mobility and legal status are different. Perhaps we lack a coherent approach to solving the problems of adolescent pregnancy and childbeanng ~ the Unite] States ~ part because of the eno~ous HiRiculties involved In designing a policy that is sensitive to our diverse population of young people. In addinon, defining an appropnate role for public policy in an area that unto recently has been regarded as a private family affair is both difficult

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20 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING and delicate. Traditionally, an indiw~ual's sexual behavior has been re- garded as a personal domain in which intrusion by others-even funnily members is ~nappropnate. However, recent debates over teenagers' ex- posure to sex education in public schools, their access to family planning services, and their right to obtain an abortion have called into question the juns~iction of parents, the state, and teenagers themselves in matters of their sexual and fertility behavior. Courts are currently struggling with these issues and finding them difficult to resolve, largely because of the ambiguous relationship of adolescents to their parents and to society. At what age should teenagers have the authority to make their own dec~- sions? Under what circumstances should the state intervene? Perhaps an additional reason for the confusion and inconsistency in policies toward adolescent pregnancy and childbeanng is the failure of policy makers to take account of the nature of adolescence, its place in the life span, and the dynamics of family relationships involving adolescents. The past decade and' a half has witnessed a dramatic burgeoning of policies and programs to help prevent teenage pregnancies and to reduce the negative eEects of early childbearing. Some have been promoted and supported by the federal government; others have been initiated by states and local communities; stat others have developed Tom significant invest- ments by- private foundations and philanthropic groups. Many have been the result of productive public-pnvate partnerships. Their range and vanation def y descnption. Some have focused on individual teens as the urut of treatment; others have focused on the family. Some have pronded specialized treatments and services; others have been comprehensive in their approach. Programs have been organized ~ schools and churches, community centers and social service agencies, and clinics and hospitals. Some have been single-site programs, while others have been replicated at several sites within a region or across the nation. Despite the magnitude of human effort and monetary resources that have been directed at solving the problems of adolescent pregnancy and childbearing, we do not know as much as we need to about what works, for whom, under what circumstances, and with what intended and unin- tended effects. While our understanding of the antecedents and conse- quences of early sexual and fertility behavior has advanced significantly since 19?1l, our knowledge of effective and effluent intervention strategies has not kept pace. In part this is because many programs have been launched by creative and enthusiastic service providers who lack the necessary methodological and statistical skills, as well as the Manual

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INTRODUCTION 21 resources, to include evaluation in their program designs. In addition, the evaluation of human service programs poses numerous theoretical, meth- odolog~c~, and practical difficulties that inhibit researchers and render the quality of the results highly vanable. Few have been continued over a period of time sufficient to reveal their long-tenn effects. Perhaps most unportant, there has been no systematic effort to assess what is known (and what is not known) about the relative costs, effects, and effectiveness of alternative approaches in light of growing scientific knowledge about early pregnancy and parenting. Indeed, skeptical observers would suggest there has been little incentive to 30 So; efforts to develop solutions have stemmed from differing and frequently conflicting concepts of the problem. PUBLIC POLICE TOWN SOLACED P~GN~CY AND CHILDBEARING Addressing the problems associated with adolescent pregnancy has only recently become an explicit priority for national policy. The Adoles- cent Health Services and Pregnancy Prevention and Care Act of 1978 (TitIe V] of the Health Services and Centers Amendments Act) repre- sents the first federal legislative initiative to focus solely on the problems of early sexuality and pregnancy. Drafted and sponsored by the Carter administration, it was described by Joseph CaTifano, then Secretary of the Department of Health, Education, and Welfare, as "the centerpiece of the President's strategy to deal with the urgent problem of teenage pregnancy across the nation" (April 13, 1978~. Throughout the 1960s and 1970s, the federal government assumed a more and more active role in providing and financing pregnancy-related programs. Under the Child Health Act of 1967, Title V of the historic Social Security Act of 1935, maternal and child health funds were tar- geted at reducing infant mortality. Special project grants, administered by the Bureau of Maternal and Child Health Services, were made directly available to local health departments to pronde comprehensive care to children and teenagers in low-income families and to improve pregnancy outcomes through pre- and postnatal care services. Under the Family Planning Services and Population Research Act, Title X of the Public Health Services Act of 1970, federal funds were allocated for support of family planning projects, including expanded accessibility tO coIltracep- tive sernces for low-income women, the development of improved methods of family planning, personnel training, and the preparation and

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22 ADOLESCENT SEXUALITY PREGNANCY; AND CHILDBEARING distribution of educational matenals. All these initiatives benefited ado- lescents as a subgroup of the larger at-risk population. Yet it was not until passage of the Title V] legislation that Congress specifically ac- knowledged the problems of increasing sexuality and pregnancy among young unmarried teenagers. In 1978 the Office of Adolescent Pregnancy Programs (OAPP) was established in the Public Health Service to administer the Adolescent Pregnancy Prevention and Care Program mandated by the 1978 leg~sTa- tion and to coordinate all programs in the U.S. Department of Health, Education, and Welfare concerned with aspects of adolescent pregnancy and childbeanng. Despite its stated concern with pregnancy prevention among adolescents, however, the program initially concentrated almost exclusively on developing comprehensive services for pregnant and par- enting teenagers. This categoncal initiative was short-lived, however. After less than three years, during which 38 local projects received grants, the program was dismantled. Consistent with the Reagan ad- ministratio:3-,s philosophy of returning control of health and human services to the states, the appropnation was folded into the Maternal and Child Health Block Grant In 1981. Also In 1978, Congress amended the Family Planning Services and Population Research Act of 1970 (Title X) to speaEcaDy require that programs authorized under the act also provide services to adolescents. Contraceptive sernces were and are available to teenagers through sev- eral other federal programs, including the maternal and child health and social sernces programs that were made block grants in 1981, and through Medicaid. Yet Title X is currently the largest federal initiative addressing the problem of adolescent pregnancy. In fiscal 1983, the program served 4.5 million ~ i~riduals, more than a third of whom were under the age of 20 (Alan Guttmacher Institute, in press). The leg~sla- i~on encourages, but does not require, parental notification for minor teenagers to receive contraceptive services. The Reagan administrator tried unsuccessfully to place the Title X legislation into a block grant in 1981 and again in 1984. Formal authonzaiion for Title X expired in 1985, and during the remainder of 1985 and 1986 the program operated under a continuing resolution. In 1981 the Omnibus Budget Reconciliation Act repealed the Adoles- cent Heaith Sernces and Pregnancy Prevention and Care Act, replacing it with the Title XX Adolescent Family Life Act. Like its ill-fated

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INTRODUCTION 23 predecessor, the Adolescent Family Life Act represents an explicit ac- knowledgment by Congress that the federal government should address the problems of increasing adolescent sexual activity, pregnancy, and childbearing. In contrast to the 1978 legislation, however, the Adoles- cent Family Life Act places more emphasis on prevention of early sexual activity and less emphasis on the provision of contraceptive services, while retaining the previous program's commitment tO providing care for pregnant and parenting teenagers. The prevention focus is primarily on promoting abstinence from premarital sexual activity through the development of strong family values. Contraceptive services to adoles- cents are not a major component of the program, since originators of the legislation presumed that such services are adequately pronded under Title X. Program funds may not be used for abortion or abortion counseling. Adoption is emphasized as an important alternative to a~o- lescent parenting. The legislation authorizes support for research and demonstration projects rather than permanent programs, the intent being to stimulate the development of innovative approaches that state and local, public and private funding sources can sustain. The legislation also specifies that all demonstration programs include rigorous evalua- tion, but it does not provide adequate funding for this component. Legislative authority for the Adolescent Family Idle Program was re- newed for one year in 1984 and expired in 1985. In 1986 it operated under a continuing resolution. Cntics of the program argue that itS approach tO prevention is inap- propriately moralistic. Moreover, a lawsuit brought by the American Civil Liberties Union on the grounds of entanglement of church and state in the administration of the program could adversely affect itS chances of reauthorization. Although the Title X and Title XX pro- grams are supposed tO be independent of one another, they have become linked in recent legislative deliberations. The House of Representatives has demonstrated a stronger interest in the reauthorization of Title X, and the Senate appears tO be more committed to continued support of Title XX. Government involvement in addressing the problems of adolescent pregnancy has not been limited to federal policies and programs. By 1985, nearly half the states had taken steps to develop their own re- spouses to growing public concern about these issues. These initiatives have ranged broadly from coordinated statewide policies, to agendas for

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24 ADOLESCENT SEXUALITY PREGNANCY ACID CHILDBEARING action by governors' blue-r~bbon task forces, to single-agency programs and local isolated efforts to address the special needs of teenagers at high risk of pregnancy or parenthood (Kimmich, 19851. Illinois, for example, initiated a major program to coordinate the efforts of state-level educa- tion, health, and welfare agencies and to supplement Aid to Families With Dependent Children (AFDC) with targeted services. New York and North Carolina have launched programs to stimulate and facilitate local initiatives. California is developing networks of services with strong case management components. The governor of Maryland, among others, has established a special task force to assess the extent of the problem in that state, to identity existing programs that can be mobilized, and to develop recommendations for action. Some states have coupled these types of initiatives with public information campaigns and technical assistance to local service providers; others are supporting evaluation studies to document the results of their programs. Most states that have identified adolescent pregnancy and chiidbeanng as a priority have deEned an important aspect of their role as linking and mobilizing private and voluntary groups, such as churches, parent organizations, an] community youth organizations, to work with public agencies and to build a broad base of public concern and support. As federal and state support for adolescent pregnancy programs in- creased dunug the 1970s, interest in understanding the causes and conse- quences of early pregnancy and childbeanng also expanded. The Center for Population Research within the National Institute of Child Health and Human Development was created by presidential directive in 196& and given an explicit research agenda by the Family Planning Services and Population Research Act of 1970. As with the service provisions of Title X, the initial research emphasis was not on adolescent pregnancy but on more general issues related to population and family planning. In the mid-19 70s, faced with dramatic increases in sexual activity and pregnancy among teenagers, the Center for Population Research tar- geted adolescent pregnancy as a priority for research support. Over the past decade, the center has administered a broad program of research on the antecedents and consequences of early sexual and fertility behavior, including the collection of national survey data on adolescent sexuality, contraceptive use, and pregnancy resolution. When the legislation was reauthonzed in 1981, authorization for research was transferred to the general authonty pronded by the Public Health Sentence Act for research by the National Institutes of Health, thus relieving the population

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INTRODUCTION 25 research program from farther dependence on the reauthorization of the . . . sernce prowslons. The Title XX Adolescent Family Life Act also contains a strong research component in keeping with the view of Congress that more and better information on the causes and consequences of adolescent sexual and fertility behavior is needed, especially information on prevention, abortion, repeat pregnancy, aIld the short- and long-term implications of adolescent childbearing and parenting. Since 1982, the Office of Adoles- cent Pregnancy Programs has supported studies of[amilial, institutional, and societal influences on early sexual behavior and adoption, as well as the provision of services to pregnant and parenting teenagers. Studies of factors affecting contraceptive use by sexually active adolescents and ways to encourage more diligent use have not been OAPP priorities. Foundations have also played an important role in increasing knowI- edge about early pregnancy and childbearing and about the effectiveness of various interventions. The knowledge gained from research over the past decade has played an important role in the continuing debate over policies and programs. Throughout 1985, congressional hearings were held on the issues involved ~ adolescent pregnancy, and several new pieces of legislation were drafted, offering a variety of approaches for national policy. Some emphasized services to help young people complete their education and prepare for jobs, on the theory that having an education and career goal wig motivate teenagers to avoid becoming pregnant or having a repeat pregnancy. One proposed the establishment of school-based health care, family planning, and prenatal care services. Another has proposed more comprehensive approaches, including family life education, contracep- i~ve services, abortion services, and care for pregnant and parenting adolescents. Still another proposed the establishment of a block grant program to provide support for state health and welfare agencies to operate programs to prevent teenage pregnancy and to help pregnant 2nd parenting teens. There will undoubtedly be further activity in Congress and many state legislatures ~ the coming year or two, al- though the direction of legislative action is still uncertain. Debate con- t~ues over whether public policy can best and most appropriately ad- dress the problems of early unplanned childbearing by taking a pragmatic approach to teenage sexuality and pregnancy, or whether it should foster sexual abstinence among young people and greater respon- sibility Ad authority among their parents.

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26 ADOLESCENT SEXUALITY; PREGNANCY; AND CHILDBEARING THE CHARGE TO THE PANEL Our study has three major components. The first is a renew and assessment of data on trends in teenage sexual and fertility behavior. Many of the public data on incidence of sexual activity by age, sex, race, and cohort in the United States, as well as trend data on pregnancy, abortion, childbeanug, marriage, and adoption, are scattered across federal and private data banks and national surveys. Some of these data have not been previously published. Therefore, our first task was to assemble available data on trends in teenage sexual and fertility behavior and lo assess their quality. The second component of the study is a renew and synthesis of the research on the antecedents and consequences of adolescent pregnancy and childbeanug. A growing body of research from several disciplines has examined individual and societal factors that affect early sexual activity, contraceptive use, pregnancy, abortion, and childbeanng. Simi- larly, there is an extensive literature on the social, economic, and health consequences of early pregnancy and childbeanng for young mothers and their children, and to a lesser extent for young fathers. Although compilations and critiques of relevant research have been done before, the disparate and in some cases uneven threads of current research have not been systematically reviewed and synthesized. Nor have their meth- odolog~cal and theoretical strengths and weaknesses been adequately assessed. Accordingly, our second task was to critique the existing literature tO Cats the current state of knowledge and tO provide a basis for identifying fixture directions for research and analysis. The third component is a rewew of alternative preventive and amelio- rative interventions. Given the enor$nous vanety of existing programs and approaches, questions emerge concerning relative COStS, effects, and effectiveness. Are some interventions more appropriate than others for adolescents of different ages and gender, living in different social, eco- Comic, and cultural circumstances? Are certain institutions more appro- pnate than others for the establishment of various types of programs or for reaching different target populations? Are some otherwise attractive approaches tOO expensive to implement on a large scale? To begin to answer these questions, the pane! undertook a broad examination of existing interventions, both those focused specifically on adolescent pregnancy and those focused more generally on problem behaviors of young people. [nformaiion from several sources including the avail

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INTRODUCTION 27 able evaluation literature, discussions with knowledgeable researchers, service prodders, and policy makers, and firsthand viSitS to many programs-was assessed as a basis for developing conclusions and recom- mendations concerning promising directions for future programs. Policies and programs designed to affect adolescent sexual and fertility behavior touch on deeply felt values. No review of ex3 sting statistics will Itimately resolve disputes arising from different moral and political orientations. Nevertheless, a broad interdisciplinary synthesis of what is known about the antecedents and consequences of early pregnancy and childbearing and a dispassionate assessment of the somal and behave oral effects of alternative programs will senre several important purposes. First, it win help to clarify the issues, sharpen awareness of crucial decision points, and focus attention on the trade-offs and complementar- ities among different positions. Second, it will bring together In one source the many types of pertinent data that researchers, policy makers, Finding agencies, and service providers regularly need. Third, it Wii] identif y gaps in data collection and analysis. Finally, and perhaps most unportant, such a review of available evidence will pronde a useful contribution to the continuing debate of this salient but often divisive issue, and it Wii1 suggest promising directions for Future initiatives to address the problems of adolescent pregnancy. A CONTEXTUAL FRAMEWORK For every young person, the pathway from sexual initiation to parent- hood involves a sequence of choices: whether to begin baring inter- course; whether to continue sexual activity; whether to use contracep- tion and, if so, what method to use; if a pregnancy occurs, whether to seek an abortion or carry the pregnancy to term and give birth; whether to marry, if that is an option; and, if a child is born outside mamage, whether to relinquish it for adoption or raise it as a single parent (see Figure Ink. Whether consciously or unconsciously, actively or passively, aD adolescents make choices about their sexual and fertility behavior. These have significant implications for their own development and life options, for their families, and for society (Moore and Burt, 1982~. Each choice is complex, and each is significantly influenced by circum- stance end by the available options. The histoncal time and the ecological setting are central, as are the special psychosocial, physical, and percep- tual characteristics of the young person and his or her age and life

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28 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING r-- I All teenagers __ No initiation l of intercourse ~ I Contraceptive use 1 Initiation of intercourse I Marriage before I intercourse - No contraceptive use /\ - Effective contraception Miscarriages I Abortions -- 1 ~ Adoption I 1 Remain in / parental home . / / Nonmarita3 I pregnancy Nonmarital birth I .~ | No conception Marriage before birth (legitimation) I parenthood | /~ 1 \t Marriage Establish new | \ ~ I household I 1 marriage l FIGURE 1-1 Sequence of decisions affecting adolescent sexual and fertility behavior.

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INTRODUCTION 29 experiences. At any given point in time, for adolescents living in differ- ent social, economic, and cultural contexts and having different personal characteristics and life histories, choices concerning sexual behavior wit] reflect different degrees of rational thinking and conscious decision making. Similarly, at different points in time, choices by the same individual wig vary because his or her historical, social, or cultural milieu has changed. Variations in the timing and sequence of events and choices during adolescence are significant because of their implications for coherent or discordant pattems of human development (Elder, 1980~. Completion of education, ieav~ng home, marriage, and economic independence are commonly regarded as baseline indications of the transition to adult- hood, yet the timing of these events spans a wide range and may differ dramatically for individuals in different circumstances (Modell et al., 1976~. The order and spacing of these events can also vary widely. Marnage may occur before the completion of schooling, and parenthood may precede marriage and economic independence. Such variations have important implications for an individual's social identity, personal inte- gration, and life chances (Elder, 1968, 1975~. For society, such variations often constitute problems when social institutions are unable to adapt. The problems of adolescent pregnancy and childbearing, therefore, are intimately related to the timing, sequence, and circumstances of choices concerning sexual and fertility behavior, as well as to an individual's and society's ability tO adapt and promote a steady course toward adulthood (i.e., independence, responsible parenthood, and economic self- sufEciency). Efforts tO prevent pregnancy or ameliorate the consequences of early childbearing have given rise to a multiplicity of interventions targeted to the discrete choices in the sequence of sexual decision making. Most of these involve direct approaches, that is, interventions specifically in- tended to influence the decision-making process at the time of choice (e.g., family planning services to encourage the use of contraception, pregnancy and abortion counseling to affect decisions concerning preg- nancy resolutions. As Dryfoos (1984a, suggests, they are aimed at en- hancing young people's "capacity to avoid early childbearing" by in- creasing their level of knowledge about reproduction and their access to appropriate services. Others involve indirect approaches, that is, inter- ventions intended to alter the conditions of decision making the eco- log~cal context of the individual and his or her personal characteristics

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30 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING te.g., remedial education to improve academic performance and life- planning programs to help teenagers establish educational, occupa- tional, and family formation goals). Such programs are aimed at enhanc- ing young men's and womerl's "motivation to avoid parenthood" by making them cognizant of the consequences of early childbearing on their own lives (Dryfoos, 1984a). Some interventions are intended to affect more than one choice (e.g., comprehensive prevention ap- proaches) and therefore have multiple goals. Because choices at each successive point in the sequence depend on the outcomes of previous decisions, interventions aimed at later decisions are relevant to smaller numbers of teenagers. All young people must decide whether to become sexually active; only those who initiate intercourse must decide whether to use contraception; only those who become pregnant must decide whether to seek an abortion or to bear a child; only those who bear a child must deade whether to relinquish it for adoption or to raise it, either within or outside marriage. Yet as Moore and Burt (1982) point out, despite their smaller constituencies, interventions aimed at later decision points tend tO entail greater public involvement and greater public costs. Sexual activity, pregnancy, and parenting have different implications for teenagers of different ages. An unintended pregnancy or birth can have serious social, economic, and psychological consequences for ado- {escents, yet the personal problems and public issues are somewhat different for 18- and 19-year-olds than they are for those under age 18. Most 18- and I9-year-olds have completed high school; some live apart from their parents and are economically independent. In most states, they have reached the age of legal majority. In contrast, most teenagers under the age of 18 have not completed high school; most still live at home and depend on their parents' support. As minors they are under the lega~junsdiction of their parents. Throughout this report, the panel has been attentive tO this difference. To the extent that available data permit, we have distinguished patterns of sexual and fertility behavior by age. In reviewing the research on the antecedents and consequences of early pregnancy and childbearing, we have given special attention tO the effects of age on attitudes, behavior, and outcomes. In reviewing the evidence on program effects and effectiveness, we have considered issues of access tO aIld availability of services as they influence patterns of use among teenagers of different ages. The pane! has questioned fundamentally whether interventions are

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INTRODUCTION 31 needed and how they can be effective in helping teenagers to make better dec~sior~s about their sexual and fertility behavior. The sequence of choices constitutes a contextual framework for relating the personal and societal antecedents of adolescent pregnancy and parenting to the costs, effects, and effectiveness of alternative intervention strategies. It pro- vid~s a basis for identifying gaps in existing knowledge, for considering new approaches to problem solving, and for mapping promising inter- vention strategies. STRUCTURE OF THE REPORT The findings, conclusions, and recommendations of the Panel on Adolescent Pregnancy and Childbeanng are presented in the remaining chapters of this report. Chapter 2 summarizes the available data on trends in teenage sexual and fertility behavior and assesses their adequacy and reliability. Chapter 3 discusses the societal context of adolescent pregnancy. Chapter 4 focuses on the individual teenager, examining individual attributes that contribute to early sexual behavior and dec~- sion making. Chapter 5 summarizes the state of knowledge concerning the social, economic, and health consequences of early pregnancy and parenting. Chapters 6 and 7 examine what we know about the costs, effects, and effectiveness of alternative interventions. Chapter 8 presents the panel's conclusions and recommendations for future data collection and research. And finally, Chapter 9 presents the panel's Mews concern- ing priorities for future policy and program development.

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