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AN ARTICLE HOSTED BY IMPREGNORIUM.NET TEENAGE PREGNANCY Although the rate of teenage pregnancy in the United States has been declining, it remains the highest in the developed world. Approximately 97 per 1,000 women aged 15–19 — one million American teenagers — become pregnant each year. The majority of these pregnancies — 78 percent — are unintended (AGI, 1999a). Moreover, because the average age of menarche has reached an all-time low of about 12 or 13 years (Potts, 1990), and because four out of five young people have sex as teenagers (AGI, 1999a), a greater proportion of teenage girls are at risk of becoming pregnant than ever before. The consequences of adolescent pregnancy and childbearing are serious and numerous: * Teen mothers are less likely to graduate from high school and more likely than their peers who delay childbearing to live in poverty and to rely on welfare (Annie E. Casey Foundation, 1998).
As a result, the United States needs a number of initiatives to reduce its teenage pregnancy rate and the negative outcomes that accompany it. These initiatives should incorporate medically accurate sexuality education and information in the schools and in the media, improvements in funding for and access to family planning services, and youth development programs to improve the life options of impoverished teens. However, none of these initiatives can succeed without a general reassessment of the attitudes and mores regarding adolescent sexuality in the U.S. Presently, an unrealistic emphasis is placed on preventing adolescent sexual behavior, which overlooks the fact that sexual expression is an essential component of healthy human development for individuals of all ages (Freud; Maslow et al., as cited in Zimbardo, 1992). The majority of the public recognizes this fact — 63 percent of Americans believe that sexual exploration among young people is a natural part of growing up (SIECUS, 1999). An influential minority of individuals promotes unrealistic, abstinence-only education and parental consent requirements for obtaining contraception that deny American teens accurate information about and confidential access to family planning services to prevent pregnancy. However, even individuals who support parental consent and abstinence-only programs recognize the dangers of such measures. For example, in a 1998 debate over mandating parental involvement for teens using Title X-funded clinics for contraceptive services, Rep. Tom Coburn (R-OK), a radical opponent of family planning, conceded that "if we put in the [parental notice] language, some additional young women will get pregnant [and] some will get a sexually transmitted disease" because they will be deterred from seeking out services when they are no longer guaranteed confidentiality (Saul, 1999). Planned Parenthood believes that policymakers must accept the fact that teens engage in sexual behavior, and they must initiate and provide funding for various programs and interventions that will facilitate responsible sexual behavior.
Medically accurate sexuality education that begins in kindergarten and continues in an age-appropriate manner through the 12th grade is necessary given the early ages at which young people are initiating intercourse — 7.2 percent of students nationwide report having sex before the age of 13, 42.5 percent by grade 10, and 60.9 percent by grade 12 (CDC, 1998). In fact, the most successful programs aimed at reducing teenage pregnancy are those targeting younger adolescents who are not yet sexually experienced (Frost & Forrest, 1995). "Balanced and realistic" sexuality education programs that encourage students to postpone sex until they are older, but also promote safer sex practices for those who choose to become sexually active, have been proven effective at delaying first intercourse and increasing use of contraception among sexually active youth. These programs have not been shown to initiate early sexual activity or to increase levels of sexual activity or numbers of sexual partners among sexually active youth (Berne & Huberman, 1999; Kirby, 1997). Sexuality education programs in the United States currently caution young people to not have sex until they are married. Of the 69 percent of school districts with a policy to teach sexuality education, 86 percent promote abstinence as the preferred or the only option for adolescents (Landry et al., 1999). A number of studies, however, have found that abstinence-only programs are ineffective because they fail to delay the onset of intercourse and often provide information that is medically inaccurate and potentially misleading (Berne & Huberman, 1999; Kirby, 1997).
The vast majority of Americans support sexuality education for teenagers — 93 percent believe it should be taught in high schools, and 84 percent believe it should be taught in middle or junior high schools (SIECUS, 1999). Teenagers also express the need for medically accurate, responsible sexuality education: * Nearly half of high school students nationwide report that they need basic information on birth control, HIV/AIDS, and other sexually transmitted infections (STIs), and nearly half are unaware that having a sexually transmitted infection increases the risk of getting HIV if sexually active.
Medically Accurate Sexuality Education Is a Success in Other Developed Nations European countries have already demonstrated great success with responsible, medically accurate sexuality education. For example: * The Netherlands, where sexuality education begins in preschool and is integrated into all levels and subjects of schooling, boasts the lowest teen birth rate in the world — 6.9 per 1,000 women aged 15–19 — a rate almost eight times lower than that of the U. S. Likewise, the Dutch teenage abortion rate is more than three times lower than that of the U.S., and its overall AIDS case rate is more than eight times lower.
* France has a nationally mandated sexuality education program that begins when students are 13. Parents are prohibited from withdrawing their teenagers from the program. France's teenage birth rate is approximately six times lower than that of the U.S., its teenage abortion rate is more than two times lower, and its overall AIDS rate is more than three times lower. (Berne & Huberman, 1999)
Increased Use of Contraception Accounts for 80 Percent of the Recent Decline in Teenage Pregnancy The rate of teenage pregnancy in the United States has been declining — between 1990 and 1996 it decreased from 117 pregnancies per 1,000 women aged 15–19 to 97 per 1,000, a drop of 17 percent (AGI, 1999a). A flawed report commissioned by the so-called Consortium of State Physicians Resource Councils, an anti-choice organization, concluded that the recent decline in adolescent pregnancy and childbearing is a result of higher levels of sexual abstinence among American teens. The authors attribute this increase in abstinence in part to abstinence-only education (Jones et al., 1999). However, this study draws its conclusions from incomplete and non-comparable data, rendering the findings invalid (AGI, 1999b). The Alan Guttmacher Institute investigated the decline in teenage pregnancy using data from the National Survey of Family Growth (NSFG), the major source of government data on population and reproductive health. The NSFG data show that the decline in teenage pregnancy rates has occurred primarily among sexually experienced teens. The fact is that sexually active teenagers are learning to use contraception more frequently and more effectively, and they account for 80 percent of the decline in teenage pregnancy rates (Saul, 1999).
Another source of teen information about sex is the media: * In the U.S., one in four television programs contain a scene devoting primary emphasis to sexual behavior, and one in eight contain a scene in which intercourse is depicted or strongly implied, yet sexual precautions and the negative consequences of sexual behavior are rarely depicted.
The U.S. needs a long-term teenage pregnancy prevention media campaign that addresses the risks of sexual behavior. At present, most major networks do not air commercials or public information campaigns about sexual health. Developed countries such as the Netherlands, Germany, and France, in which teenage birth rates are four to eight times lower than that of the U.S., promote healthy, lower-risk sexual behavior through national media campaigns that have a high degree of influence with young women and men (Berne & Huberman, 1999).
Easy and confidential access to family planning services through clinics, school-linked health centers, and condom availability programs has been found to help prevent unintended pregnancy. In 1995, contraceptive use among women aged 15–19 years old prevented an estimated 1.65 million pregnancies in the United States (Kahn et al., 1999). Contraceptive use is also cost-effective. The average annual cost associated with unintended pregnancy and sexually transmitted infections per adolescent who uses no method of contraception is $5,758 in the private sector and $3,079 in the public sector. Access to contraception lowers this cost. For example, the contraceptive implant costs $1,533 over five years in the private sector, saving approximately $4,225 (Kahn et al., 1999). Various studies have demonstrated that efforts to improve teenagers’ access to contraception do not increase rates of sexual activity (Kahn et al., 1999; Schuster et al., 1998; Guttmacher et al., 1997; Kirby, 1997), but do yield a number of positive outcomes. For example: * The most successful adolescent pregnancy prevention programs in the U.S., which combine sexuality education with direct access to or information about contraceptive services, have increased contraceptive use among participants by up to 22 percent (Frost & Forrest, 1995).
* Condom use among students in New York City public high schools that have condom availability programs is five percentage points higher than in Chicago, where no such programs exist (Guttmacher et al., 1997).
Forty percent of sexually active teens in need of contraceptive services turn to Title X-funded clinics (Donovan, 1998). Confidential access to contraceptive services is crucial to preventing teenage pregnancy. If teenage women are denied access to both prescription and over-the-counter methods of contraception, approximately one million additional pregnancies will occur annually (Kahn et al., 1999). In Carey v. Population Services International, the U.S. Supreme Court ruled that minors have a constitutional right to privacy that includes the right to obtain contraceptives (431 U.S. 678 (1977)). Title X requires that family planning services be provided to adolescents and that minors’ confidentiality be protected by prohibiting funded clinics from releasing information from a patient’s file without her or his consent and by enforcing a fee scale that is based on the minor’s, not the parents’, income (AGI, 1995). Some state courts have adopted "mature minor" rules that authorize minors to consent to medical treatment related to sexual activity without parental consultation or permission (Donovan, 1998; AGI, 1995). However, approximately half of all U.S. states lack legislation that explicitly guarantees teenagers’ rights to consent to contraceptive services (AGI, 1995).
Expanding insurance coverage for contraception is one way to improve teenagers’ access to contraception. Many teenagers cannot afford to pay for contraceptive methods. Pills cost $180–$300 per year; injections cost $110–$170 per year; implants cost up to $750; IUDs cost up to $450 (PPFA, 1998). Many private insurance plans do not provide adequate coverage for contraception — no U.S. health care policy pays for condoms (Berne & Huberman, 1999), half of all fee-for-service plans do not cover any reversible methods of contraception and only one-third cover the pill, only 39 percent of traditional health maintenance organizations (HMOs) cover all five methods of prescription contraceptives, and seven percent do not cover any of them (Dailard, 1999). Countries with lower rates of teenage pregnancy — the Netherlands, Germany, and France — also have liberal contraceptive coverage for contraceptive pills and devices, including free contraceptive services for teenagers (Berne & Huberman, 1999). If passed, the federal Equity in Prescription Insurance and Contraceptive Coverage Act (EPICC) being debated by Congress would require all health insurance plans with a prescription drug benefit to cover contraception. Still, sexually active women will remain unprotected: one-quarter of women of childbearing age, and one-third of children under age 18, do not have private insurance (Dailard, 1999; Campbell, 1999).
Public funding for family planning could significantly help poor (family income is at or below the federal poverty level) and low-income (family income is between 100 and 199 percent of the poverty level) teenagers aged 15–19, who account for 73 percent of young women who become pregnant, even though they make up only 38 percent of all women in that age group (AGI, 1998). Poor teenagers are more sexually experienced than those of higher incomes, yet they use contraception less frequently and less successfully, and they have higher rates of pregnancy (AGI, 1998). Among women aged 15–19, 60 percent of poor women are sexually experienced, versus 53 percent of low-income and 50 percent of higher income adolescents (AGI, 1998). Nearly 60 percent of poor and low-income teenagers use some method of contraception the first time they have sex, versus 75 percent of higher income teens. Likewise, 78 percent of poor and 71 percent of low-income teenage women use contraception on an ongoing basis, versus 83 percent of higher income teens (AGI, 1998). When faced with an unintended pregnancy, many poor and low-income teens are likely to view early childbearing as a positive, desirable choice (Brindis, 1999), becoming pregnant with the misguided hope of improving their lives (Gordon, 1996). Medicaid, Title X, and the State Children's Health Insurance Program (CHIP) are three government programs that subsidize contraceptive services for poor and low-income adolescents. Publicly funded family planning is cost-effective — every dollar spent on publicly subsidized family planning services saves $4.40 on costs that would otherwise be spent on medical care, welfare benefits, and other social services to women who became pregnant and gave birth (Donovan, 1995). Of 15–19-year-olds obtaining contraceptive services, 63 percent use a publicly funded source (Forrest & Samara, 1996). Four in 10 sexually active teenagers who need contraceptive services rely upon clinics funded through Title X (Donovan, 1998). Despite these outcomes, public funding for family planning is decreasing — funding for Title X dropped 61 percent between 1980 and 1998 when inflation is taken into account (Dailard, 1999). Poor teens who cannot afford the full cost of contraception must rely upon cheaper but less effective methods (Donovan, 1995), such as periodic abstinence and withdrawal.
Although youth development programs for poor teens, such as academic tutoring, job training and placement, mentoring, and youth-led enterprise programs, have been found to significantly reduce teenage pregnancy rates (Kirby, 1997), few adolescent pregnancy prevention programs directly address the problem of poverty (Brindis, 1999). Lesbian, bisexual, and abused teens, as well as teens who are sexually involved with older partners, are more likely than other teens to experience pregnancy, and they may need specialized programs to address their specific risk behaviors and to help them obtain services. Pregnancy among lesbian and bisexual adolescents is 12 percent higher than among heterosexual teens. Lesbian and bisexual teens are also more likely to engage in frequent intercourse — 22 percent versus 15–17 percent of heterosexual or unsure teens (Saewyc et al., 1999). Teenagers who have been raped or abused also experience higher rates of pregnancy — in a sample of 500 teen mothers, two-thirds had histories of sexual and physical abuse, primarily by adult men averaging age 27 (Males, 1993). Among women younger than 18, the pregnancy rate among those with a partner who is six or more years older is 3.7 times as high as the rate among those whose partner is no more than two years older. Adolescent women with older partners also use contraception less frequently — one study found that 66 percent of those with a partner six or more years older had practiced contraception at last intercourse, compared with 78 percent of those with a partner within two years of their own age (Darroch et al., 1999). Some states are enacting or more rigorously enforcing statutory rape laws to curb teenage pregnancy among women with older partners by deterring adult men from becoming sexually involved with minors. However, experts assert that statutory rape laws will not reduce rates of teenage pregnancy, but will discourage teens from obtaining reproductive health care out of fear that disclosing information about their partner will lead to a criminal charge (Donovan, 1997).
Young men are often overlooked as a group that plays an important role in reducing teenage pregnancy. A study of high school students in North Carolina found that 14.7 percent of sexually experienced teenage men had been involved in a pregnancy in 1997 — a 38 percent increase from 1995 (DuRant, 1999). Sexuality educators and reproductive health care providers must therefore present pregnancy prevention as the job of both partners to foster responsible sexual choices among young men and women. Because young men who have unprotected intercourse also tend to engage in other risk behaviors such as fighting, carrying a gun or other weapon, attempting suicide, smoking cigarettes, drinking alcohol, and using drugs (DuRant, 1999), programs designed to address these behaviors should optimally include a pregnancy prevention component.
A shift in attitudes towards teenage sexuality must occur in the U.S. to facilitate the development of appropriate policies and programs to reduce teenage pregnancy. Presently, sexual activity, rather than the pregnancies that can result from it, is seen as the problem requiring intervention. Teaching young people that premarital sex is a moral failure does not prevent pregnancy — studies show that those with fearful and negative attitudes about sexuality are less likely to use contraception when they have sex than those who believe they have a right to decide to have sex (Reiss, 1990). Recognition that sexual expression is a crucial component of teenagers’ development will help guarantee teenagers the right to honest, accurate information about sex and access to high quality reproductive health services that will empower them to express their sexuality in safe and healthy ways. Lower teenage pregnancy rates will follow as a natural outcome.
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