Abstract and Keywords
Although rates of adolescent pregnancy have exhibited a downward trend since 1991, the United States continues to have a significantly higher rate than other industrialized nations. Adolescent pregnancy, especially in early and middle adolescence, has long-term developmental and economic impact on the teen and her child, in addition to high social costs. This entry describes the current trends in adolescent pregnancy in the United States, and examines factors reported in the research literature as associated with adolescent pregnancy, discusses federal policy directed toward adolescent pregnancy prevention, and identifies various intervention programs.
Epidemiology of Adolescent Pregnancy in the United States
The first national estimates of adolescent pregnancy rates were reported in 1976 (Ventura et al., 2006). In 1990, rates in the United States reached an all-time high of 116.3 pregnancies per 1,000 teens, meaning that 11.6 percent of teens from age 15 to 19 years old had a pregnancy that ended in a live birth, abortion, or fetal loss (National Center for Health Statistics, 2004; Ventura et al., 2006). Reports for 2002 estimated 76.4 pregnancies per 1,000 adolescent females, or 7.6 percent of females from age 15 to 19 years old, indicating a 35 percent decline in these rates between 1990 and 2002, or an average decline of 3 percent per year (Ventura et al., 2006). Estimated rates for teens under age 15 declined from 3 percent in 1990 to 2 percent in 2000 (Ventura et al., 2004). It is important to note, that nearly 20 percent of all teen births are repeat births, and that while first birth rates continue to drop, the repeat birth rate has stabilized (Abma et al., 2004; Franklin, Corcoran, & Harris, 2003). Further examination of these rates, based on age and race or ethnicity provides a more complete picture of adolescent pregnancy.
Age of the pregnant teen is a critical variable, as the impact of pregnancy on a young adolescent is much greater than on an older adolescent (Phipps & Sowers, 2002; Reichman & Pagnini, 1997). From 1990 to 2002, the rate for teens from age 15 to 17 years old decreased by 42 percent, while rates for older teens experienced a more modest decrease of 25 percent (Figure 1).
These numbers represent record lows in teen pregnancy rates since 1976 (Ventura et al., 2006). Pregnancy rates by race and ethnicity have also shown a steady decline. Rates for Black and White non-Hispanic teens experienced a 40% reduction between 1990 and 2002, with rates for Hispanic teens declining by 19% (Ventura et al., 2006). All age subgroups experienced a steady decline in rates except Hispanic teens aged 18 to 19 years, whose rate remained stable (Ventura et al., 2006). Pregnancy rates for Black teens and Hispanic teens were similar in 2002, but were still two and one-half times the rate for non-Hispanic White teens (Figure 2).
Explanation of the Decline in Teen Pregnancy Rates
Research suggests several explanations for the decline in pregnancy rates for adolescents. One is that there has been a reduction in the number of teens engaging in sexual intercourse, which includes the proportion of teens that have “ever had sex” and proportion of teens that have had multiple partners. Another proposed explanation is the increased use of effective contraceptive methods by adolescents (Boonstra, 2002; Darroch & Singh, 1999). Between 1995 and 2002, the percentage of teens who reported ever having sexual intercourse declined from 49% to 46% among females, and from 55% to 46% among males (Abma et al., 2004). In an analysis of sexual behavior and contraceptive use from the 1995 and 2002 waves of the National Survey of Family Growth, researchers found a major increase in the use of contraceptives and a decrease in non-use of contraceptives among adolescents from 15 to 19 years of age (Santelli et al., 2007). These investigators concluded that increased use of contraceptives explained 86% of the decline in pregnancy rates, while changes in sexual behavior (that is, later initiation of first intercourse) explained only 14% of the decline in adolescent pregnancy rates (Santelli et al., 2007). An additional possible cause of the declining rate is the increased attention given to the problem of adolescent pregnancy at the federal, state, and local levels, which has prompted the development and implementation of various prevention initiatives.
Impact of Adolescent Pregnancy
Adolescent child bearing has long-term negative consequences for both the teen mother and her child. Parenting in adolescence affects young women's ability to complete high school and attain higher levels of education, which subsequently affects their long-term earning capacity and socioeconomic status (Hoffman, 2006). Adolescents who bear their first child before age 15 are at even higher risk of negative socioeconomic consequences as they are much more likely to have a subsequent birth during adolescence than teens who give birth after age 15 (Boardman et al., 2006).
Studies also suggest that the negative consequences of teen childbearing may be greater on the children than on their mothers. In a study that compared children born to mothers aged 17 years or younger to children born to mothers from 22 to 29 years old, researchers found that the children born to the older group of mothers scored consistently and significantly higher on measures of kindergarten readiness such as cognition and knowledge, language and communication, learning approaches, emotional well-being and social skills, physical well-being, and motor development (Terry-Humen, Manlove, & Moore, 2005).
The cost of adolescent pregnancies is high—not only for individual teens and their families, but to society as well. In 2004, societal costs associated with adolescent parenting were estimated at $9.1 billion. These estimates included costs associated with health care, various types of public assistance, child welfare, and loss of tax revenue due to lower taxes paid (Hoffman, 2006).
Risk Factors for Adolescent Pregnancy
The literature on adolescent pregnancy is replete with studies and research reviews that identify both the risk and protective factors associated with teen pregnancy (Berry et al., 2000; Hummel & Levin-Epstein, 2005; Talashek, Alba, & Patel, 2006). Kirby and Lepore (2007) reviewed more than 400 research studies that examined factors influencing adolescent sexual behavior, and categorized the factors into four themes: (1) biological factors (that is, age, physical maturity, and gender); (2) disadvantage, disorganization, and dysfunction in the teens’ social environment; (3) sexual values, attitudes, and modeled behavior; and (4) connection to adults and organizations that discourage sex, unprotected sex, or early childbearing. These researchers identified factors that were most influential, and then scored the factors based on the feasibility of an intervention program to target change in those factors. The highest ranked factors at the individual level included sexual beliefs, attitudes, and skills of teens; highest ranked at the peer level included peer attitudes and behaviors regarding childbearing and use of contraceptives; and highest ranked at the family level included communication about sex and contraception.
Risk factors for repeat pregnancies may be more specific to the individual than first time pregnancies. In a study of 581 White, African American, and Latina teen mothers, Raneri and Weimann (2006) found that slightly more than 42% of the sample had experienced a “rapid repeat pregnancy,” defined as a repeat pregnancy within 24 months. Further, the same researchers determined the following characteristics were predictors of a second pregnancy: not using a long acting contraception within the first three months postpartum; having plans for a second child within five years; not returning to school by three months postpartum, being with an abusive partner, not being in a relationship with the father of the first child, and being in a friendship group with other adolescent parents.
It is noteworthy that not all repeat pregnancies are unintended. In a study using 2002 National Survey of Family Growth data, Boardman et al. (2006) examined risk factors for unintended versus intended rapid repeat pregnancies among teens. Among this sample, 34% of the teens reported their repeat pregnancy was intended. Risk factors associated with an intended repeat pregnancy included an intended first pregnancy, not living in an intact family, and not being married. The analysis from this study also indicated that three subgroups of teens were at higher risk for unintended, rapid repeat pregnancies: (1) very young teens, (2) teens with a history of nonconsensual sex, and (3) teens living in non-intact families.
Although most studies have examined risk factors for adolescent females, recent studies have begun to identify risk factors associated with adolescent paternity. For example, in a prospective longitudinal study of 335 urban African American males, researchers found that childhood aggression (as early as age 8 years of age) significantly predicted adolescent paternity (Miller-Johnson et al., 2004). In addition, substance use and involvement with deviant peers significantly increased the predictive effect of childhood aggression.
Temporary Assistance to Needy Families
Although there is no indication that welfare reform is effective in preventing teen pregnancy, the Personal Responsibility and Work Opportunity Act (PRWOA) of 1996 sought to legislate efforts to reduce teen and out-of-wedlock births (Nathan, Gentry, & Lawrence, 1998). Temporary Assistance for Needy Families (TANF) places limits on the amount of time an individual can receive aid and mandates work requirements intended to discourage recipients from becoming dependent on government assistance (Levin-Epstein & Hutchins, 2003). Special provisions were written into the law specifically addressing minor parents: (1) minor parents are required to live with a parent, caregiver, or in an adult-supervised setting; and (2) minor parents are required to participate in education leading to a high school diploma or its equivalent (Hummel & Levin-Epstein, 2005; Levin-Epstein & Hutchins, 2003). The full impact of this policy on outcomes for teen parents is still being assessed, but current research has not shown a significant improvement in financial success or work opportunities for parenting adolescents based on this policy (Hummel & Levin-Epstein, 2005).
For the last two decades, the U.S. federal government has consistently promoted abstinence-only education as its primary strategy for prevention of adolescent pregnancy (Kirby, Laris, & Rolleri, 2006; Trenholm et al., 2007). As of 2008, three main federal funding streams exist to support education programs that focus exclusively on abstinence as a preventive strategy: the Adolescent Family Life Act (AFLA); Title V—Welfare Reform Act; and the Community-Based Abstinence Education Program. With each new piece of legislation, guidelines for federally funded abstinence education programs have become more restrictive, including defining the terms abstinence and sexual activity as well as advocating against the inclusion of other strategies to prevent unwanted pregnancy, such as methods of contraception.
The AFLA, enacted in 1981, resulted in the creation of the first abstinence-only curriculum. It promoted chastity and self-discipline to adolescents as the key to avoiding unwanted pregnancy (Dailard, 2006). In 1996, Title V of the Welfare Reform Law purported to reduce not only the number of adolescent pregnancies, but also all out-of-wedlock births regardless of parent age (Levin-Epstein & Hutchins, 2003). Title V allocates funds in block grants to states that implement abstinence-only education curricula that teach the “social, psychological, and health gains of abstaining from sexual activity” and that “a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity” (Duberstein, Lindberg, Santelli, & Singh, 2006).
Similar to the AFLA, Title V did not include definitions of abstinence or sexual activity, allowing states the flexibility to decide what constitutes a fundable abstinence education program. A federal definition of these terms was not made explicit until 2000 when the Bush Administration implemented a third program, the Community-Based Abstinence Education Program (CBAE). The CBAE provides funding directly to community-based organizations, including faith-based agencies, to support abstinence-until-marriage education programs. In addition, the CBAE outlines eight points that describe the federal definition of abstinence education (Dailard, 2006). Unlike Title V, which allows states discretion in deciding which programs to fund, CBAE funding is awarded directly from the government to the requesting organization, and is the strictest of the federally funded abstinence programs (McFarlane, 2006). In 2006, across all three programs, the federal government committed $176 million to promoting abstinence education programs (Dailard, 2006; McFarlane, 2006) with CBAE receiving the majority of funding (Dailard, 2006). In 1997, Congress authorized a scientific evaluation of the Title V, Section 510 Abstinence Education Program. Conducted by Mathematica Policy Research Institute, the evaluation used an experimental design, randomly assigning eligible youth to one of four Title V program groups or a control group. The study found that program group youth were no more likely than control group youth to have abstained from sex, and for those who reported having sex, had similar numbers of sexual partners, and no differences in mean age of first sexual initiation (See Trenholm et al., 2007, for a detailed description of the evaluation.
Established by Congress in 1970, Title X of the Public Service Act offers affordable, confidential family planning and preventive health screenings to low-income women and adolescents. Title X Family Planning Clinics provide contraceptive and education services that prevent unintended pregnancies, as well as testing and treatment for sexually transmitted diseases (Center for Reproductive Rights, 2004). In 1981, Congress amended Title X to require grantees to encourage minors to seek family involvement in their family planning decisions, thus encouraging, but not mandating, parental involvement (Jones & Boonstra, 2004). Additional amendments have been proposed that would require parental consent for adolescents seeking Title X services. Research indicates that mandating parental involvement, and the resulting loss of confidentiality, would deter many adolescents from seeking and receiving the sexual health care services that they need (Reddy, Fleming, & Swain, 2002).
Pregnancy Prevention Programs
Specific goals of a pregnancy prevention program usually fall into four broad categories. Programs may seek to (1) delay sexual initiation, (2) improve contraception use, (3) delay first pregnancy, (4) delay repeat pregnancy among teens who are already parenting. Other psychosocial risk factors may be targeted (for example, building self-esteem), but the majority of evaluated programs focus on one, or a combination, of these four areas (Manlove et al., 2004)
Most programs focus on primary prevention, or preventing a first pregnancy. Such programs employ various approaches, and can be implemented with youth in a community setting, or a school setting either as part of a normal scheduled school day or after school (Kirby et al., 2006). Curriculum-based programs use an educational curriculum implemented over a set period. Youth development programs focus on developing leadership among teens and utilizing peer relationships to influence positive decision-making. Other approaches, such as the Baby, Think It Over program, allow teens to experience the demands of caring for a baby using an “infant simulator” that is programmed to imitate a real infant's feeding, changing, and sleeping schedule (Didion & Gatzke, 2004). As of 2008, curriculum-based programs are the most widely used format, and the approach most supported by empirical evidence (Kirby et al., 2006).
Other programs target the prevention of repeat pregnancies for already-parenting teens. These programs differ from primary prevention programs in that they provide resources and support for adolescent parents in addition to sex education. Secondary prevention programs consist of one or more of the following components: home-visiting services or case management; parenting education; vocational or educational skills; life skills; and contraceptive education (Corcoran & Pillai, 2007). Klerman (2004) conducted an assessment and review of programs that sought to interrupt the intergenerational cycle of early childbearing. Klerman's findings indicated that several factors may significantly impact the effectiveness of these programs: (1) service location and the provider's ability to form a relationship with the participant; (2) training of program personnel; (3) service initiation and length; (4) fidelity of program implementation; and (5) definitions and measures of success.
Evaluation of a program's effectiveness must take into consideration the population served, as few programs can be applied universally. Depending on the specific goals and approaches, certain pregnancy prevention programs may show varying results based on participant characteristics such as gender, age, race, and ethnicity (Kirby, Laris, & Rolleri, 2006). Therefore, in reviewing programs, it is important to take these factors into account. Kirby, Laris, & Rolleri (2006) reviewed 83 curriculum-based programs (national and international) that demonstrated effectiveness in reducing pregnancy and rates of sexually transmitted infections. Half of the programs reviewed used a randomized control design and the others used a quasi-experimental design. The study results showed eight content characteristics of curriculum-based programs that demonstrated effectiveness. They include: 1) focused on prevention of HIV, STDs, and/or unintended pregnancy; 2) specifically addressed behaviors leading to these goals, gave clear messages about these behaviors, and addressed ways to avoid situations leading to these behaviors; 3) focused on specific psychosocial factors affecting these behaviors and changed some of those factors; 4) created a safe environment for youth to participate; 5) included instructionally sound activities designed to change targeted risk and protective factors; 6) employed teaching methods that actively involved participants, helped participants personalize the information and were designed to change targeted risk and protective factors; 7) employed activities, instructional methods and behavioral methods appropriate to the youths’ culture, developmental age, and sexual experience; and 8) presented topics in a logical sequence. (See Kirby, Laris, and Rolleri, 2006, for a detailed description of the programs, their characteristics, and the results of the evaluations.)
School-Based Health Centers
School-based health centers (SBHCs) were established in the 1970s to ensure that adolescents have convenient access to important health care services (Rounds & Ormsby, 2006). However, the inclusion of reproductive health and family planning services has drawn criticism from various groups that hold that the availability of these services may encourage promiscuity and undermine parental authority (Morone, Kilbreth, & Langwell, 2001). Types of services offered by an SBHC vary and are largely influenced by the state and local environments. As of 2008 there are approximately 1,400 SBHCs in 43 states across the United States. Funding for SBHCs is provided by various sources, including federal and state grants (such as Title X family planning and Title V MCH block grants), Medicaid, and private insurance (Kanaan, 2003; Morone et al., 2001).
An overarching goal of SBHCs is to make health care services, including mental health screening, prevention services, and counseling, accessible to the underserved adolescent population. SBHC offers a comprehensive service delivery system within the school that relies on collaboration among school administrators and community service providers (Olbrich, 2002). Social workers working in school and community health agencies serve important roles in facilitating these collaborations, providing needed services, and advocating for adequate and appropriate mental health care for youth. Addressing the mental health needs of adolescents minimizes the risk for development of serious psychological and social problems and academic failure.
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