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OCR for page 15
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
OCR for page 16
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
OCR for page 17
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.
OCR for page 29
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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Representative terms from entire chapter:
sexual activity
