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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.