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OCR for page 189
7
J
Interventions for Pregnant
ant! Parenting Adolescents
Like the growth in interventions designed tO prevent or delay preg-
nangy among adolescents, there has also been dramatic growth in the
number and vanety of interventions designed tO assist pregnant and
parenting teenagers and their children. And since 197S, there has been an
increase In services for women who decide against carrying their pregnan-
aes tO teem Programs designed to overcome the negative health, social,
and economic consequences of early childbeanug have beers tiated by
the federal government, by states and localities. and by unvate founda-
tions and philanthropic groups.
a.. . . .. .
~ ms chapter aescnbes interventions of five general types:
· those that provide abortion sentences;
· those that provide prenatal and pennatal health care services;
· those that pronde economic support;
· those that improve the somai, emotional, and cognitive development
of the children of teenage mothers;
· those that enhance the life options of teenage parents.
The first category, abortion services, provides an alternative tO childbear-
ing once a pregnancy has occurred. Programs in the next three categories
pronde services to pregnant and parenting teenagers to meet their unme-
~iate health and subsistence needs and to improve the development of their
children. They are intended tO directly improve the health and weD-being
of young mothers land to a iirnite] extent young fathers) and their
children. Programs in the last category are aimed at er~hancing adoles-
cents' motivation to become mature and economically self-sufEic~ent indi
189
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190 ADOLESCENT SEXUALITY PREG.~AA7CY AND CHILDBEARING
visuals and sensitive, responsible parents. They are intended to indirectly
improve the health and social and economic weD-being of young mothers,
young fathers, and their children by helping them want to help them-
seIves.
Among the numerous programs that are in operation, many provide
specialized services to meet short-term health, financial, and social service
needs (e.g., prenatal care, nutrition sentences, income supports). Others are
more comprehensive, providing a mix of needed supports and seances. In
addition, while some interventions directly affect health and economic
we0-be~g, others influence factors such as educational attainment and
employability that in turn affect these outcomes.
The short-term and long-term goals of some programs may differ. For
example, helping a young mother obtain Aid to Families With Depen-
dent Children (AFDC) support and stay in her parental home during her
pregnancy and for a period immediately following the birth of her baby
may ultimately enhance her ability to become economically self-suffIc~ent
and live independently. The measures of success for such a program are
different at different points In time. Some programs have been care~hy
evaluated and demonstrate clear positive effects; others have shown less
encouraging results; Stir others have not been rigorously assessed, and
some have not been evaluated at aD. In short, as with preventive inter~ren-
tions, knowledge of the relative effects and electiveness of alternative
approaches is incomplete. Yet accumulated program experience and a
growing body of evaluation data provide some insights concerning how
and how wed venous interventions work, for whom, under what circum-
stances, at what COStS, and with what intended and Nintendo conse-
quences.
The remaining sections of this chapter summarize what is known about
programs related to the Eve categories.
ABORTION SERVICES
Induced abortion became legal nationwide in the United States In 1973.
In some states abortions became legal somewhat earlier, however, and
illegal abortions have long been obtained by those who knew where to go
and could pay for services. Although the availability of legal abortion
services does not cause abortion, it has been associated with increased use,
as discussed in Chapter 2. Although the legality of abortion and the
availability of abornon services remain controversial, a variety of recent
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PREGNANCY AND PARENTING INTERVENTIONS 191
public opinion polls suggest that more than two-thirds of U.S. women
agree or agree strongly that a pregnant woman should have the right tO
decide whether she warts tO terminate a pregnancy and that she should
have access to legal services to do so (Yankelov~ch, SkeDey, and White,
1981, as reported by Henshaw and Mart~re, 1982; A~C/Washington Post,
1982; NBC, 1982; CBS/New York Times, 1980; Hams, 1979).
Abortions are performed in hospitals, freestanding clinics (some of
them nonprofit, others for-proEt), priorate physicians' ounces, and a few
family plowing clinics. By 1980, Freestanding abortion clinics provided
more than thre~quarters of ad legal abortions. Most of the other quarter
are performed ~ hospitals (Henshaw et al., 1984~. Nmety-~ve percent of
the nonhospita] abortion providers offer contraceptive services as wed. A
quarter of family planning clinics pronde abortion services at the same site
or at another site in the same agency (Chamie et a]., 1982), but there are
strict restrictions against using any federal family planning fiends for
abortion services. Many short-stay general hospitals do not pronde this
service, and no Roman Catholic hospital does so. In addii~or~, 58 percent
of obstetucian-gynecolog~sts report that they do not perform` the proce-
dure for moral or religious reasons or because they lack access to equipped
hospital facilities (Orr and Forrest, 1985~. Very few nonhospital family
planning clinics perform abortions (although they routinely refer patients
to other sernce providers).
Abortion providers vary to some degree in their policies and the specific
services they offer: 72 percent wiD perform an abortion through the tenth
week of gestation; 32 percent wig perform one at 13 weeks; 21 percent at
15 weeks; and only 5 percent at 21 weeks (Henshaw et al., 19841. While
some clinics consider abortions at 13 and 14 weeks to be second-nimester
procedures, others do not. When surveyed, however, 82 percent Chicane
that they do not perform abortions after the fist trimester of pregnancy.
Larger clinics (with a caseload of 2,500 or more) and those that operate for
profit are more likely tO perform second-erunester procedures than ficili-
ties with caseloads of less than 1,000. Hospitals are more likely than clinics
or private physicians to perform abortions at later gestations (Henshaw et
at., 19~.
virtuaDy Al abortion clinics pronde contraception counseling either on
the day of the procedure or at the foDow-up nsit: 85 percent of clinics give
or sed contraceptives tO the client on their premises on the day of the
procedure. Ad clinics make abortion counseling available on request; such
counseling generally consists of descnb~g the procedure and expla~n~g
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192 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING
its risks, obtaining informed consent, and confirming that it was the
patient's own decision to have the procedure. Henshaw (1982) reports
that 90 percent of clinics routinely counsel a] first-abortion parents; 88
percent of clinics pronde decision counseling to help a young woman
explore the venous factors that are involved in making an informed
decision about the termination of her pregnancy. Nonprofit clinics appear
to place greater emphasis on counseling than for-proEt facilities. As a
matter of policy, 68 percent of clinics pronde a pregnancy test before
perfonning an abortion, even when a test has been pronded elsewhere. In
addition, 93 percent routinely pronde a post-abortion clime visit.
In recent years, several states have passed legislation requiring parental
consent or a judicial bypass of parental consent (i.e., minors can petition
courts to allow the procedure without parental consent) for minor adoles-
cents to obtain abortions. Regalness of state laws, however, some pro-
nders independently require parental consent for the procedure. A 1981
study reported that parental consent for minors is not required by three-
quarters of abonionclin~cs, but 15 percent report that they always require
consent for a minor to obtain services, and an additional 7 percent report
that they require it under certain circumstances (e.g., if the client is under
age iS) (Henshaw, 19821. An earlier study found a larger proportion of
clinics requinug parental consent for all minors, especially for those under
age 15 (Torres et al., 19801. Of the 1,170 unmarried abortion patients
under age 18 surveyed in the earlier study, 44 percent were 17 years old, 32
percent were 16, 17 percent were 15, and 7 percent were 14 or younger. A
majority reported that their parents knew they were obtaining an abor-
tior~. The younger the patient, the more likely she was tO report that her
parents knew and the more likely she was to have been referred to the
clinic by her parents. Approximately 25 percent of the teenagers surveyed
In this study sea] they parents did not know and that they would not have
come to the clinic if parental consent or notification were requiem (Torres
et al., 1980~. A recent study of the impact of the parental notification
requirement In Minnesota found that approximately 43 percent of adoles-
cent minors surveyed used thejudinal bypass alternative rather than notif y
both parents of their desire tO obtain an abortion; about a quarter of them
reported having noticed one parent (Blurn et al., 1985~.
In mid-1983, noIlhospital facilities charged an average of $227 for an
abortion at 10 weeks with local anesthesia "d $230 with general anes-
thesia (Henshaw et al., 1984~. (The fees of nonprofit cynics were DOt
significantly different from those of for-profit clinics-Henshaw, 1982.)
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PREGNANCY AND PARENTING INTER FENTIONS 193
By companion, hospital charges, including the doctor's fee, are higher.
They averaged S73; in 1981, including an average of $330 for the
doctor's fee. Second-trimester abortions were more expensive, although
the increase in charges was greater for clinic procedures than for hospital
procedures (Henshaw, 1982~. When questioned about how they were
paying for art abortion, 30 percent of girls under age 18 reported that
their mate partner was prodding payment; 26 percent reported that
their parents were paying; 18 percent said they were sharing the ex-
penses with their male partner or parents; 18 percent said that Medicaid
was paying; and 8 percent said they were providing paymeIlt alone. Giris
IS or younger were most likely to report receiving financial help from
parents. (These data were collected during a penod when the federal
government was not paying for abortions under Medicaid except when
the mother's life was threatened or when the pregnancy occurred as a
result of rape or incest, but a number of states were paying for abortions
to women eligible under Title XIX of the Social Secunty Act Torres et
al., 1980~.
Alan Guttmacher Institute researchers conclude that many young
women do not have access to abortion services, even though services
have expanded dramatically in this country since 1973. In 1980, 6
percent of U.S. residents obtaining abortions did so outside their state of
residence (Henshaw and O' Reilly, 1983~. Teenagers traveled an average
of 45 miles from home to obtain services, many outside their county of
residence (Torres et al., 1980~.
What effects has the nationwide legalization of abortion had on rates
of childbearing and on the sexual and fertility behavior of adolescents
who have terminated a pregnancy? The available evidence consistently
shows that rates of childbeanng have decreased since 1973 in states and
countries with higher abortion rates (Henshaw, 1983; Field, 1981;
Brann, 1979; Moore and CaldweD, 1977~. Concern that the availability
of abortion services win lead to higher rates of sexual activity and
pregnancy and less reliance on contraception is not supported by the
available research literature. As discussed in Chapter 4, the availability of
abortion does not appear to affect either sexual activity or the probability
of becoming pregnant. Koenig and Zel~k (1982) found that an adoles-
cent girl who aborted a first pregnancy was significantly less likely to
become pregnant again within 24 months than a comparable girl who
earned her first pregnancy to term. Implicit in this finding is the fact that
gigs who have terminated a pregnancy practice contraception more
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194 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARI.~G
effectively after the procedure than before. From a public health point of
view, the total number of pregnancy-related deaths averted between
1973 and 1983 by the replacement of unwanted and mistimed births and
illegal abortions with legal abortions to American women (including
teenagers) is estimated to be approximately 1,500, and the number of
life-threateniIlg but not fatal complications averted probably reached
several tens of thousands (Tietze, 1984~.
In 1977, the federal government imposed restrictions on the availabil-
ity of Medicaid fending for abortions, and since 1981 Medicaid abortions
have been fi~nded only if the mother's life would be endangered by
carrying the pregnancy to term. This curtailment of public funding
appears to have had little impact on rates of abortion or chil~lbeanug
among adolescents, since about 80 percent of Medicaid-eligible women
(including teenagers) living in states that discontinued publicly subsi-
dized abortion paid for the procedure themselves in 1978 (TrusseD et al.,
1980~. In addition, in many states, the number of Medicaid-funded
abortions was very limited even when support was available from the
federal government. As a result, the Imposition of federal restnctions
had little effect on abortion rates in these jurisdictions (Cates, 1981~.
Evidence suggests, however, that the cuto~offederal funding has caused
many Tow-income women, including adolescents, to delay their abor-
tions because of difficulties In obtaining the money needed to pay for
services. For those affected, the delay has averaged approximately two to
three weeks. For some this has meant that the abortion was postponed
until the second trimester of pregnancy (Henshaw and Wallisch, 1984),
thus increasing the health risks associated with the procedure.
Parental notification and parental consent statutes enacted in a num-
ber of states in recent years similarly appear to increase the likelihood that
a pregnant teenager will delay obtaining an abortion, thereby increasing
the possible health risks (Donovan, 1983~. Although there are no out-
come studies available on notice statutes, Melton "d Pliner (1986) argue
that unless such provisions actuary result in parental consultation, they
are likely to simply present hurdles that reset ~ delay.
States that revue consent by one or both lining parents have included
provisions for "bypassing" parents and seeking the approval for an
abortion from a judge. Typically these statutes require a two-level
inquiry. First, if thejudge Ads the minor to be mature, her privacy must
be respected. Second, if the minor is immature, the judge must deter-
mine whether an abortion would be in her best interest. As a matter of
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PREGNANCY AND PARENTING INTERVENTIONS 195
practice, most proceedings have turned Out to be pro forma endorse-
ments of Unknots' decisions (Melton and Pliner, 19861. Most minors are
found to be mature, and abortions are almost always found to be in the
best interest of immature minors. In Massachusetts, for example, be-
tween Apn] 1981, when the consent statute took effect, and February
1983, about i,300 minors sought an abortion through the judicial
bypass procedure. In 90 percent of the cases the minor was judged to be
mature; ire the remaining cases, all but Eve requests for abortions were
approved, according to the best interest standard. In three of the cases
denied, the trial court's decision was overturned on appeal; in one case
the judge instep the minor to seek approval from another judge, who
granted the petition; and in the last case the minor decided to go to a
neighboring state for an abortion (Mnookin, 1985~. Similar findings
have been reported in Minnesota (Donovan, 1983~.
Because it takes several days to obtain access to the courts and may
require travel outside one's resident county, there is a de facto waiting
peno] associated with the judicial bypass procedure. This delay gener-
ally necessitates a teenager's missing school and may lead to a postpone-
ment of the abortion depending on how fonnidabie the process of
obtaining a lawyer and going to court turns out to be (Melton and
Pliner, 1986~. In both Massachusetts and Minnesota, which have
adopted parental consent requirements, there has been a marked drop
(approximately one-third) in the number of adolescent abortions, appar-
enely as a result of minors choosing to go to neighboring states and
thereby avoid the judicial bypass procedure (Donovan, 1983; Mnookin,
19851. It is unknown whether the parental consent statutes are increas-
ing the numbers of unwanted children born to teenagers (Melton and
Pliner, 1986), and no research has systematically examined the psycho-
log~cal effects of ehesejudicial procedures on the minors who go through
them.
There are few studies of the psychological effects of abortion among
teenagers. Most of the available research deals with adult women or
mixed samples that have not separately examined adolescents. Although
abortion is a stressful experience, most studies have found that it is not
likely to cause severe emotional problems, particularly among women
who do not have preex~st~g psychological problems, and frequently the
response is one of relief (AdIer and DoIcini, 1986~. The same appears to
be true for adolescents (Olson, 1980), although several studies found an
association between age and psychological after-effects lamer, 1975;
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196 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING
Bracken et al., 1974; Adler and DoIcini, 19861. Adier and Doicini (1986)
suggest that, while statistically significant, the magnitude of the differ-
ences between teenagers and Bruit women is not generally very great and
the negative reactions of adolescents (primarily depression) are Stiff gen-
erally mild. Factors that may contribute to the comparatively more nega-
tive response of adolescents include gestational stage, delay in obtaining
an abortion, and social supports. In addition, Kummer (1963) found
- r ~
that pnmiparous women, including teenagers, who have had a previous
induced abortion appear more prone to depression during their next
pregnancy than women who have not had aI1 abortion. Severe emotional
responses are very rare (Maracek, 19861. Despite these findings, the
existing body of ewdence on this matter is not conclusive and further
study focused specifically on adolescent Uris is needed. Similarly, very
little is known about the effects of an abortion on young mate partners,
in part because many abortion clinics exclude them from counseling.
The male perspective on abortion seems to be important in itself and also
because the attitudes and reactions of male partners are likely to affect the
young women undergoing the procedure.
PROGRAMS THAT PROVIDE HEALTH CARE SERVICES
The health care needs of pregnant girls and of young mothers and their
babies are numerous A vanety of specialized sernces to fill those needs
exist, including prenatal care and delivery, pediatric care, family plan-
ning and reproductive health care, nutritional services, and health educa-
tion (e.g., first aid, nutrition, sex education, and hygiene). Given cur-
rent knowledge and technology, it is possible to prevent or ameliorate
many of the most burdensome matemal and child health problems.
Maternal aIld child health services and health promotion activities are
available in most communities through a variety of public and private
providers.
Prenatal Care and Delivery
A substantial literature suggests that timely prenatal care plays an
important role in preventing problems such as prematurity and low
b~hweight, especially among low-income, minority, and adolescent
girls, who are regarded as high-nsk (Strobino, Vol. Il:Ch. o; Institute of
Medicine, 1985; Sin gh et al., 198~; Shadish aIld Reis, 1984~. Complica-
tions of pregnancy are more likely to occur among women who receive
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PREGNANCY AND PARENTING INTER MENTIONS 197
no prenatal care until the third trimester of pregnancy or who receive no
prenatal care at all (Kesse] et al., 1984~. In recognition of these facts,
national objectives have been for~nuiated to emphasize the importance of
making good prenatal care available to all women (Singh et ale, 19851:
the Surgeon General has called for an increase to 90 percent by 1990 in
the proportion of women in age, racial, and ethnic risk groups who
receive `:are in the first trimester (Golden et al., 1984~. The standards of
maternity care developed by the American College of Obstetricians and
Gynecologists, now widely accepted in practice, recommend that every
woman have a comprehensive program of prenatal care, beginning as
earlyin the first trimester as possible. For uncomplicated pregnancies the
standards recommend regular visits every 4 weeks for the first 28 weeks
of pregnancy, one crisis every 2 weeks for the next 8 weeks, and weekly
visits during the last 4 weeks or until delivery (American College of
Obstetncians and Gynecologists, 19821.
Available data on trends in the use of prenatal care sermces show that
use increased among all age and racial groups during the 1970s; use of
services is now widespread throughout the United States, although not
at the levels prescnbed by the Surgeon General (Singh et al., 1985~. Data
also show that the proportion of minority women and teenagers who
received such care remained at lower than average levels during the
1970s, and between 1980 and 1982 there was a decline in the proportion
of 15- to 19-year-olds of aD races receiving first-tnmester care (National
Center for Health Statistics, 1983, 1984a). Using "no prenatal visits at
aD or no nsits Unto the th=d tnmester" as a measure of inadequate
prenatal care, Singh et al. (1985) found that women from low-income
backgrounds and those who are young, nonwhite, and unmarried and
who have completed less than 12 years of school are at substantially
greater risk of inadequate care. They conclude that the need for educa-
tion concerning the importance of adequate health care dun ug preg-
nancy and publicly fi~nded services to provide such care are especially
important for those who are poor, those who are teenagers, and those
who are unmarried.
A variety of programs has been initiated to help high-nsk adolescents
obtain adequate prenatal care. Many are prowded through public health
departments, university hospitals, freestanding clinics, school-based
clinics, and youth-serving agencies as wed as by private physicians. Some
of these Institutions provide prenatal care as a special service; others sense
pregnant adolescents in the context of more comprehensive programs.
Cost is one important factor influencing teenagers' use of prenatal
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198 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARL~G
care services. Maternity care is expensive. The Health Insurance Associa-
tion of America estimated that in 1982, total estimated costs for an
uncomplicated delivery were more than $2,300, and a cesarean delivery
cost nearly $3,600 (Health Insurance Association of Amenca, 1982~. In
1985 these costs were likely to total more than $3,200 for a normal
delivery and $0,000 for a cesarean delivery (Gold and Kenney, 1985~.
Teenagers disproportionately rely on Medicaid and other federal ma-
ternal and child health programs lo pay for their prenatal health care an]
labor and delivery. They are therefore more likely to attend clinics than
to receive care from private physicians. Because of low levels of reim-
bursement, about half of physicians offering obstetric services do not
participate in Medicaid (Gold and Kenney, 19851. In addition, pregnant
girls sometimes have special problems in obtaining Medicaid coverage.
Girls under 18 who live in a household receiving AFDC are entitled to
Medicaid-subsidized care. However, they usually need to present a par-
ent's Medicaid card at the clinic, and many teenagers delay the initiation
of care rather than confront their parents with their pregnancy before it
is obvious. For adolescents living in households that do not receive
AT:DC and who are unwilling or unable tO obtain their parents' support
for prenatal care, most generally leave home and establish separate house-
holds if they want to receive Medica~-subsidized care (Gold and Ken-
ney, 1985~. In addition, in some states the waiting period for a medical
assistance card following venfication of the pregnancy typically delays
early receipt of care. Similarly, in some states cards are issued for two-
month periods and renewal may be a Occult and time-cons~ing
process, thus discouraging some teenagers from seeking prenatal services
(Maryland Governor's Task Force on Teen Pregnancy, 1985~.
Teenagers in some states may be able to adroit some of the gaps in
Medicaid coverage by virtue of a requirement that Medicaid-eligible
individuals under age 21 receive seances through the Early and Periodic
Screening, Diagnosis and Treatment Program (EPSDT). Although it iS
not clear to what extent states use this provision tO sense pregnant
teenagers, there is some endence that eligible adolescents covered under
this prograTn may receive a more generous package of services than is
prodded to other Medicaid recipients (Gold and Kenney, 1985). The
Maternal and Child Health block grant (MCH) also offers some fle~bil-
ity ~ filling gaps ~ Medicaid coverage. MCH funds are not reimburse-
ments, but rather direct grants to hospitals and clinics to pronde sennces
to target populations. Emphasis is on the provision of care to mothers
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PREGNANCY AND PARENTING INTER MENTIONS 199
and children in poverty, and institutions are prohibited from charging
fees. MCH provisions clearly state that monies may be used for prenatal
care; however, the use of funds for hospital deliveries is more ambigu-
ous, especially if the young mother is not "high risk" (Gold and Kenney,
19851. Unfortunately, as Gold and Kenney (198;) conclude, MCH does
not require certain minimum services, does not specify eligibility, and
does not require accountability in the use of the funds. It is thus difficult
to know what proportion of teenagers benefit from these block grants
relative to other publicly subsidized services.
Another important factor affecting the timeliness of teenagers' initiat-
ing prenatal care is delay in obtaining pregnancy testing and counseling.
Because many adolescent girls fail to recognize the early signs of preg-
nancy or choose to ignore them, they do not initiate prenatal care during
the first trimester. Programs that make pregnancy testing easily accessi-
ble, confidential, and free or at very low cost to teenagers have been
shown to help in getting young expectant mothers into prenatal care
earlier (Nicke] and Delany, 19851. School-based clinics and other free-
standing clinic facilities that are sensitive to the special needs of adoies-
cents may be especially effective in this regard. In addition, many school-
based clinics provide prenatal care on site and therefore are easily
accessible to pregnant teenagers who remain in school. Most of these
programs emphasize frequent contact with clients; when students miss
regularly scheduled appointments, the staff are able to contact them at
school (Kirby, 19851. The St. Paul, Minn., school-based clinics demon-
strated favorable outcomes: in 1982 the proportion of pregnant teenag-
ers at these clinics who began prenatal care in the first trimester was very
high, 94 percent, compared with slightly over half among a comparable
national sample of white teenage mothers (Hofferth, Vol. Il:Ch. 91.
Other hospital-based and community-based programs directed at get-
ting teenagers into prenatal care early and keeping them in care through-
out their pregnancy have also been successful. The Improved Pregnancy
Outcome Project (IPO), conducted by the University of North Caro-
lina, was intended tO improve outcomes among a sample of poor, rural,
black young women. The project used nurse-midwives to provide pre-
natal and postpartum care and pronded outreach and transportation
services as part of a comprehensive counseling, education, and health
care package. The project showed a significant increase in the proportion
of teenagers who received adequate prenatal care, although there was no
effect on the birthweight of their infants (Hofferth, Vol. Il:Ch. 9~. The
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220 ADOLESCENT SEXUALITY; PREGNANCY AND CHILDBEARING
developed strong ties to the business community and have depended on
local employers as advisers and future employment resources for their
participants (Nickel and Delaney, 19851.
Family Care Programs
- - -1
For the adolescent mother who chooses single parenthood, several
alternative living arrangements are theoretically available. She and her
child may establish an independent household, alone or with other
unrelated individuals. She may continue to live with her parents in their
home or with other relatives. Or she may establish residence in a foster
home or group facility. Her decision is usually influenced by her own
preferences, her parents' feelings, available financial resources, and her
needs for a variety of types of assistance (Klerman, 19831.
Research suggests that while the young mother and child in an
independent household may have food, shelter, and medical care pro-
~rided, the absence of other individuals, especially supportive adults, may
have negative consequences for her and her child. Young mothers living
on their own are more likely to drop out of school because of problems in
locating adequate child care and the lack of parental encouragement,
which is likely to have negative effects on her employability and her
child's cognitive development. The absence of parental supervision may
make sexual activity and contraceptive neglect easier, thus leading to
rapid subsequent childbeanug. In addition, beanug the full burden of
childrearing may cause frustration that leads to inadequate childreanug
(Klerman, 1983; Baldwin and Cain, 1980; Kinard and Klerman, 1980~.
These findings support the notion that family-based care in the adoles-
cent's family of origin, with relatives, OF with a supportive foster
family may be beneficial tO the young single mother and her child
(Klerman, 1983; Furstenberg and Crawford, 1978; Zitner and Miller,
1980~.
The potential bereft of family support for pregnant and parenting
teenagers has stimulated numerous efforts to encourage and strengthen
family caret Most ofthese have involved the inclusion of grandparents or
other family members in existing agency programs for adolescent moth-
ers through home nsits, interviews and follow-up, and special group
activities for families. In addition, some agencies have initiated special
counseling an] support activities for the families of pregnant an] parent-
ing teenagers. As Klerman (1983) points out, many families need assis
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PREGNANCY AND PARENTING INTERVENTIONS 221
tance in dealing with the trauma surrounding the pregnancy itself, as
well as the conflicts that inevitably arise when a new family unit is
incorporated into the existing one. New grandparents may also require
help In managing their new two-generation childrearing roles (Stokes
and Greenstone, 19811.
Advocates of such programs suggest that major social and economic
benefits are likely outcomes for example, school completion, delays in
subsequent childbearing, employment, reduced need for welfare for
young mothers, and enhanced physical, psychological, and cognitive
development for their children (Klerman, 1983; Ooms, 1981~. How-
ever, careful analysis of the short-term and Tong-term effects of these
programs has not been done. It remains for future research and program
evaluation to confirm or disprove these claims.
Role Models and Mentonug Programs
Recognition that many teenagers, including those who are parents,
are frequently reluctant to seek assistance until a problem becomes a
crisis, several programs have been initiated to help them take advantage
of the services that are available. Among these approaches are mentonng
programs that use trained adult community voinnteers as role models tO
help them overcome the Ninety of personal and social difficulties that
their pregnant and impending parenthood create.
The most visible of these interventions has been the community
women component of Project Redirection, in which volunteers who
were not professional caseworkers were drawn from the community,
trained, and assigned tO participants when they enrolled in the program.
The community women helped to communicate with teenagers and
reinforce the messages of the program: the need tO obtain adequate
medical care Cuing and after pregnancy; the need tO stay in school and
graduate; the need to delay subsequent childbeanng; the need tO be a
responsible and canny parent; the importance of work as the key to
independence; and the importance of clarifying personal priorities for
male-femaTe relationships (Quint and Riccio, 1985~. Community
w-omen helped their teenagers get to needed sernces, offered advice and
practical assistance, and senred as a listening ear. They also played a
critical role in program operations, extending the capacity of the regular
staff and helping tO develop effective strategies for dealing with the
individual problems of the girls (Quint and Riccio, 198;~.
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222 ADOLESCENT SEXUALITY; PREGNANCY AND CHILDBEARING
The community women component of Project Redirection was not
separately evaluated for its effects on schooling, employability, or subse-
quent fertility; however, reports of the program highlight some of the
special strengths and weaknesses of this aspect of the overall program.
Predictably, the quality of the relationship between individual teenagers
and their community women varied with personalities and c~rcum-
stances. Observers report that the relationships were often particularly
close when the young women became estranged from their own fami-
lies. For such a participant the community woman sometimes served as a
surrogate mother. By the same token, many teenagers who were dissat-
is:Sed with the program attributed their dissatisfaction to alienation
from their community women. In addition, high rates of turnover,
common among many volunteer programs, also affected the community
women component. Only 22 percent of the volunteers enrolled at the
outset in 1980 were still active in 1982. Stafflearned that the volunteers
required support, nurturing, and reinforcement if they were to be effec-
tive and that charismatic individuals who are strongly committed can
make a difference (Quint and Riccio, 19851.
Unfortunately, the Project Redirection evaluation does not provide
deE=tive evidence of the effectiveness of mentonng programs in attain-
ing the education, work, parenting, aIld fertility outcomes that were the
goals of the program. It does, however, suggest the need to farther
examine role models as a potentially useful approach to reaching preg-
nant and parenting teenagers.
Comprehensive Care Programs
During the late 1970s, there was growing public and professional
awareness that most pregnant and parenting teenagers have multiple
needs and that many of the sernces they required were "fragmented,
inefficient, and inadequate" (Forbush, 1978~. In response, comprehen-
sive care programs became the preferred approach for assisting the target
pop~anon, many of whom come from severely econom~caby disadvan-
taged backgrounds. The 1978 Adolescent Health Sernces and Preg-
nancy Prevention Act endorsed this intervention model, and since the
late 1970s comprehensive care programs have been developed in several
communities across the country. Typically, their goals have been (1)
continuation of education, (2) delay of subsequent pregnancies, (3)
acquisition of employability and job skills, (4) improved maternal and
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PREGNANCY AND PARENTING INTER MENTIONS 223
infant health, and (5) acquisition of life management skills. Their general
approach has been to provide a comprehensive mix of health care,
education, and social services on-site and in coordination with other
local agencies. Core services have included parental, postpartum, and
pediatric health care, remedial education, employment training and
counseling, family planning services, life planning assistance and life
skills training, and parenting education. In addition, many comprehen-
sive care programs have featured a case management approach, whereby
indiw~uaTized service plans are developed on the basis of individual needs
assessments.
Hofferth (Vol. II:Ch. 9) descnbes and critiques the findings of several
of the most visible comprehensive care programs:
· Project Red*ection, supported jointly by the Ford Foundation and
the U.S. Department of Labor and evaluated by the American institute
for Research and the Manpower Demonstration Research Corporation;
· The Too Early Childbearing Network, supported by the Charles
Stewart Mott Foundation, evaluated by Deborah Walker of Harvard
University and Anita Mitchell of the Southwest Regional Laboratory;
· The Adolescent Family Life Comprehensive Care Projects sup-
ported by the federal Office of Adolescent Pregnancy Programs and
evaluated by the Urban Institute;
· The Adolescent Pregnancy Projects, also supported by the OAPP
and evaluated by IRB Associates;
· The Young Mothers Program, operated by the Yale-New Haven
Hospital and evaluated by Lorraine Klerman, then at Brandeis Univer-
sity, and James Tekel, then at Yale University;
· The Prenatal/Early Infancy Project, operated by the University of
Rochester School of Medicine and evaluated by the program staff;
· The Johns Hopkins Adolescent Pregnancy Program, operated by
the Johns Hopkins University Hospital and evaluated by the program
staff;
· The St. Paw Maternal-Infant Care Program, operated by St. Paul
Ramsey Hospital aIld evaluated by the program staff; and
· The Rochester Adolescent Maternity Project, operated by the Uni-
versity of Rochester School of Medicine and evaluated by the program
staff.
The outcomes of specific aspects of these programs have been dis-
cussed throughout this chapter in the context of separate intervention
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224 ADOLESCENT SEXUALITY PREGNANCy AND CHILDBEARING
components. Se~rerai more general findings are of special interest. First,
among the programs reviewed, there was strong evidence of positive,
short-te~ effects in their particular areas of concentration. That is,
programs tended to improve outcomes for those areas on which they
were specifically focused, for example, reducing the number of repeat
pregnancies or keeping pregnant teenagers in school. Substantial Tong-
te~ effects, however, especially on delay in subsequent fertility, have
yet to be demonstrated. While clients have been shown to do well while
they are in the comprehensive care programs, their later health, educa-
tion, and employment outcomes are less positive. Those who remain in
the programs longer appear to do better than those with shorter tenures
(Polit-O'Hara et al., 1984; Klerman and Jekel, 1973), but it iS IlOt clear
whether these apparent benefits are due tO the program or to the self-
selection of committed participants.
Second, two of the programs had their most positive effects on their
most disadvantaged participants, suggesting that those in greatest need
may denve the greatest beneDt from comprehensive care programs (Olds
et al., 1983; Polit-O'Hara et al., 1984~. Other programs, however, had
difficulty reaching the youngest teenagers, regarded by many as the
population ~ greatest need (McAnarney and Bayer, 19811.
Third, among programs that rely on a brokerage modei, the quantity
and quality of services depends on what is available in local communities.
While this mode] may be sensible from the standpoints of administration
and COSt control, it may hamper the programs from responding ade-
quately and appropriately to the needs of enrollees, espec~aDy younger
ones (Quint and Riccio, 1985; Burt et al., 19841. Moreover, when
services are brokered rather than delivered directly, monitonug the
quality of these services and teenagers' participation in them is more
difficult.
Fourth, there is some evidence from the several evaluation studies that
pregnant and parenting teenagers may require a somewhat different mix
of services depending on their age; organizations that serve the youngest
adolescents may not be weD suited to serve older ones. While adolescent
parents and parerlts-to-be in all age groups require the same health
sernces, school-age teenagers need more supports and sernces to help
them complete their education. Many younger teenagers remain in their
families of origin during and after their pregnancies, suggesting the need
for more supports for their families as well. Older teenagers are more
work-onented and therefore typically require services to enhance their
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PREGNANCY AND PARENTING INTERVENTIONS 223
employability. Because many 18- and 19-year-olds are living indepen-
dently, they may reseed more life management support (Walker and
Mitchell, 1985; Quint and Riccio, 1985~.
Fifth, comprehensive care programs are costly. Data on costs were not
available for all of these programs, and they vary depending on the mix of
services and the locality. For example, Project Redirection's operating
costs averaged approximately $3,900 per participant per year; these costs
are only partial, however, in that they reflect costs borne by the sponsor-
ing agency but not those of outside agencies providing the brokered
services (Quint and Ricao, 1985~. The operating costs of the projects
sponsored by OAPP averaged $2,6;0 per participant per year for 7 of the
26 projects. Costs were higher for young mothers who entered the
program after delivery than for those who entered during their pregnan-
c~es (Burt et al., 1984~.
Ah of the comprehensive care programs that were renewed included
an evaluation component, and among them Hofferth (Vol. Il:Ch. 9)
observes a trend toward more rigorous research designs, including ran-
domiy assigned treatment and comparison groups, planned variations in
treatment, and sophisticated controls for avanety of intervening factors.
She also highlights several significant limitations of these studies. Unfor-
tunately, none of these evaluations, even the most sophisticated, sepa-
rately analyzed the impact of venous components of the program. In the
evaluation of Project Redirection, for example, it is impossible to assess
the relative effects of the individual participant plan, the community
women, and peer group sessions on participants' educational, employ-
ability, life management, and health outcomes.
The selection of control groups also poses problems in interpreting the
findings of several studies. The OAPP projects lacked a control group
altogether. The Too Early Childbeanng Network has sought to develop
controls for its projects using existing national and/or local comparison
data. However, Hofferth (Vol. Il:Ch. 9) suggests that while this is a
useful approach, in some cases it has resulted in an overstatement of
program effects because the matched data are not comparable in terms of
race, socioeconomic status, age, marital status, etc. The Project Red~rec-
iion control group was the most carefully matched among the program
evaluations that were reviewed. However, researchers conducting the
evaluation expressed concern about the difficulty in finding "pure"
controls in the communines in which the programs were operating, as a
basis for assessing the benefit of the sentences offered ire the programs.
_ ~. ~ ~
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226 ADOLESCENT SEXtJALITY PREGNANCY; AND CHILDBEARING
Because of the wide variety and growing number of programs and
services for pregnant and parenting teenagers, they had difficulty identi-
fying a totally unserved control group.
The comprehensive services model is based on an assumption that
certain essential resources exist at the local level, including (~) basic
health, educational, and social services and funds to operate them, (2)
political and popular support, (3) clients, and (4) effective interventive
technology (i.e., proven theory for program design). However, a recent
study (Weatherly et al., 1985) found many of these basic resources
lacking. Adequately funded services with well-tramed service prodders
were often unavailable or inaccessible; local support was frequently
limited; and interventive approaches were frequently "overlaid with
ideology and pragmatic concerns for organizational maintenance"
(Weatherly et al., 19851. In addition, these researchers confirmed a
finding from several of the evaluation studies, that pregnant and parent-
ing teenagers are an inherently difficult group to senre in conventional
bureaucratic settings. Because they are a diverse population (e.g., age,
developmental matunty, race, socioeconomic status, family status, aspi-
rations and expectations), they require individualized assistance.
Weatherly et al. (1985) found that a programmatic choice to serve any
part of this diverse population often entailed an implicit decision to
exclude others. In short, these researchers found that few "comprehen-
sive care" programs for pregnant and parenting teenagers actually meet
their goals. They are limited in geographical coverage and the numbers
served relative to need. Moreover, and perhaps most ~rnportant, while
some programs do show positive short-term effects, for example, on
reducing the number of repeat pregnancies, there is little evidence that
these programs are able to remedy many of the other conditions that are
associated with early unintended childbearing.
Weatherly et al. (1985) were able to specify necessary conditions for
program success: well-developed loch health, education, and social serv-
ices, local civic cultures supportive of services, flexible local funding
sources, traditions of interagency collaboration, mechanisms for local
coordination, and supportive state policies. However, they conclude
that few localities possess these resources, and effective comprehensive
care programs can be developed and maintained only under exceptional
circumstances.
In sum, the existing research and evaluation literature on comprehen-
sive Cave programs provides little evidence that these interventions con
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PREGNANCY AND PARENTING INTER MENTIONS 227
stitute a solution to the problems associated with early unintended
pregnancy and childbeanng. While they can provide short-term support
and services to young women in crisis, they do not address many of the
more fundamental conditions that lead to adolescent pregnancy and that
undermine successful adjustment, including poverty and unemploy-
ment.
Adoption Services
Among those adolescents who carry their pregnancies to term, some
are unwilling or unable to care for their children. For these young
women, adoption services which facilitate the termination of their
parental rights and permanently place their children in unrelated adop-
tive families provide an alternative.
There are strong indications from agency data that the number of
young women interested in relinquishing their children is declining. In
Minnesota, for example, there were 6,107 births to teenage mothers in
1982 and only 4; newborn adoptions in 1983 and in 1984 (data presented
by lane Bose, Children's Home Society of Minnesota). However, the
actual numbers nationwide and the magnitude of the trend are not clear.
it seems that more young unmarred mothers who glare birth are keeping
and raising their children than one or two decades ago, although there
appears to have been little change in the propensity of teenage mothers to
place their babies for adoption since the m~-1970s (Bachrach, 1986~. In
addition, there has been a substantial decline in the rate at which children
born outside marriage are adopted by unrelated persons (Muraskin,
1983~. However, agency data alone do not provide a reliable source on
this matter, since private adoptions (arranged between individuals rather
than through an agency) have become more prevalent dunug the past
several years ~ some states. Despite the apparent decline in the number
of women choosing adoption over parenting, there has been renewed
interest in programs to enhance the adoption alternative in the early
1980s. The Adolescent Family Life Program passed by Congress In 1981
as Title XX of the Public Health Service Act places high priority on
finding ways to make adoption an attractive option to unmarried teenag-
ers who become pregnant.
Adoption services generally include education and counsei~g for the
birth mother during her pregnancy (and sometimes afterward), prenatal
care, nutrition services if they are needed, obstetrical care for labor and
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228 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING
delivery, identification and selection of adoptive families, and legal serv-
ices to carry out the relinquishment by the birth mother and adoption by
the new family. As Muraskin (1983) points out, in some cases these
sernces are provided as a comprehensive package in ~ residential facility.
Residential programs, however, seem to be the exception. More often,
more than one agency or service provider is involved in the process.
Teenagers rarely go to an adoption agency for pregnancy testing; there-
fore, if they are seriously considenng relinquishment, they mu* be
referred to a public or private adoption agency by a family planning clinic
or other facility that provides pregnancy testing and counseling. Most
adoption agencies arrange and refer clients to the necessary health and
social sernces they require dunug pregnancy, labor, and delivery but do
not usually pronde these services on-site. Although they typically screen
and select adoptive families and handle the legal aspects of the relinquish-
ment and adoption proceedings, they generally do not pronde counsel-
mg and support for the birth mother after she has relinquished the child
(Muraskin, 1983~. This fragmentation of needed sernces may serve as a
disincentive for some pregnant teenagers to make adoption plans.
Research on adoption decision making and adoption sernces is sparse.
The Office of Adolescent Pregnancy Programs as a part of its mandate
under the provisions of the Adolescent Family Life Act has commis-
sioned two studies to address these issues (Kallen, 1984; Restack, 1984~.
As Muraskm (1983) suggests, however, much more extensive research
on the effectiveness of adoption services, for both the young birth
mother and for adoptive families, is needed.
CONCLUSION
Over the past three decades a variety of programs to reduce the
individual and societal costs of early childbeanug have been developed
and implemented in communities across the COUIlt~J. Policy makers and
service providers have approached problems of teenage parenthood from
a variety of professional and philosophical perspectives. As McGee
(1982:6) observes:
Doctors and health workers have been concerned about the health consequences
[for mothers and children]. Schools have been concerned about drop-out rates
among pregnant [end parenting] teenagers. Soaalworkers have been concerned
about illegiiimaq and the problems of young-parent families. Family planning
professionals have been concerned about the inconsistent use of contraception,
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PREGNANCY AND PARENTING INTER MENTIONS 229
the rapid repeat pregnancy rate among young mothers, and the increased
reliance on abortion. Policy analysts have been concerned about the increasing
use of public assistance by teen mothers.
Several researchers have concluded that the result of this plethora of
service providers and interventions is not, as one might expect, an
oversupply of services to pregnant and parenting teenagers (Moore and
Burt, 1982; McGee, 1982; Klerman, 1983; Alan Guttmacher Institute,
1981; Weatherly et al., 1985~. Instead, they believe that many necessary
supports and services are unavailable, and those that are available are
often inaccessible, inappropnate, or do not cover the population in need.
Moreover, although many of the interventions described in this chapter
represent interesting and innovative program models with the potential
to help overcome the negative social, economic, and health consequences
of early childbearing, we know frustratingly little about their COStS,
effects, and electiveness.
Only a few programs have been rigorously evaluated; many have not
even collected basic pretest arid pastiest data to indicate outcomes along
specified dimensions. Among those for which outcome info' citation is
available, there is some evidence of positive short-term ejects on tar-
geted goals:
sing;
· The availability of abortion services effectively prevents childbear
· Prenatal care can produce healthy outcomes for the young mother
and her baby;
.
· Nutntion services can help reduce the~cidence of low birthweight;
· RegllIar preventive pediatric care can improve the health of infants
and young children;
· Contraceptive services c" Increase birth control use and coni~nua-
tion;
· income support can improve the economic well-being of disadvan-
taged adolescent families, both those living independently and those
Ming in someone else's household;
· Child care seances can facilitate young mothers' return to school or
entry into thejob market;
· Parenting education can improve teenage parents' knowledge of
Plant and child development and child care and can prevent early devel-
opmental delays In their children;
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230 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING
· Alternative school programs can help pregnant and parenting teen-
agers stay in school and can boost their academic achievement;
· Employment programs can teach job skills and place teenagers in
jobs.
There is little information on the longer-term effects of these interven-
tions, although evidence from the available research suggests that success
in achieving the short-term goals may assist adolescents to become
mature and economically self-sufficient individuals and sensitive, re-
sponsible parents.
Evaluations of comprehensive care programs have not analyzed the
impact of separate service components on teenagers' capability and moti-
vation to overcome the problems associated with early childbeanng.
Thus, there is little basis for judging which aspects of these programs,
either singly or in combination, have the greatest promise for producing
positive outcomes. Moreover, although the available evaluations suggest
that many programs have the potential to effectively help teenagers
through the crisis of pregnancy, birth, and the early months of parent-
hood, there is no evidence of sustained, positive effects over time. In part
this may be because such interventions cannot address the fundamental
problems in many young people's lives that preceded the immediate
circumstances oftheir pregnancy. In part, however, it maybe because the
time frames for evaluating these programs have not been long enough.
Outcomes at 12 months and 24 months after delivery have been shown
to be quite different along several dimensions. It may well be that at 5-
year, 10-year, and 15-year follow-ups, the outcomes would look quite
different. Certainly Furstenberg and Brooks-Gunn's (1985b) Baltimore
research suggests that, over time, many early childbearers, even those
from the most disadvantaged backgrounds, do find pathways to success.
Despite the complexity and expense of longitudinal research, long-term
follow-ups of samples of clients from selected programs may yield valu-
able understanding of the strength an] duration of program effects.
Representative terms from entire chapter:
prenatal care
