Risk Behaviors

In the United States, teen pregnancy is an important problem. In 1997, the last year for which accurate estimates are available, about 896,000 young women under the age of twenty became pregnant. Among women aged fifteen to nineteen, 94 per 1,000 (or about 9%) became pregnant. This rate is much higher than that in other Western industrialized countries. In addition, according to a 1997 publication of the National Campaign to Prevent Teen Pregnancy, more than 40 percent of young women in the United States become pregnant one or more times before they reach twenty years of age.

The U.S. pregnancy rate is higher for females aged eighteen and nineteen (142 per 1,000) than for females fifteen to seventeen (64 per 1000). It is also higher for African Americans (170 per 1,000) and Hispanics (149 per 1,000) than for non-Hispanic whites (65 per 1,000). Much of this ethnic variation, however, reflects differences in poverty and opportunity.

On the positive side, the 1997 teen pregnancy rate in the United States was the lowest pregnancy rate since it was first measured in the early 1970s. The rate fluctuated considerably over the course of the 1970s, 1980s, and 1990s, however, reflecting both changing percentages of youth who have sex and improved use of contraception among those having sex.

While the teenage pregnancy rate is, by definition, based upon female teenagers, this does not mean that all the males involved in these pregnancies are teenagers. Indeed, in 1994, whereas 11 percent of fifteen-to nineteen-year-old females became pregnant, only 5 percent of fifteen-to nineteen-year-old males caused a pregnancy.

About four-fifths of teen pregnancies are unintended. Accordingly, in 1997, 15 percent of all teen pregnancies ended in miscarriages, 29 percent ended in legal abortions, and 55 percent ended in births.

Among mothers under the age twenty, the percentage of births that occur out of wedlock has risen dramatically–from 15 percent in 1960 to 79 percent in 2000. This large increase in and high rate of non-marital childbearing has alarmed many people and motivated many efforts to reduce teenage pregnancy.

Consequences of Teen Childbearing

According to a 1996 report written by Rebecca A. Maynard, when teenagers, especially younger teenagers, give birth, their future prospects decline on a number of dimensions. Teenage mothers are less likely to complete school, more likely to have large families, and more likely to be single parents. They work as much as women who delay childbearing for several years, but their earnings must provide for a larger number of children.

It is the children of teenage mothers, however, who may bear the greatest brunt of their mothers' young age. In comparison with those born to mothers aged twenty or twenty-one, children born to mothers aged fifteen to seventeen tend to have less supportive and stimulating home environments, poorer health, lower cognitive development, worse educational outcomes, higher rates of behavior problems, and higher rates of adolescent childbearing themselves.

Although the greatest costs are to the families directly involved, adolescent childbearing leads to considerable cost to taxpayers and society more generally. Estimates of these costs are in the billions.

Adolescent Sexual and Contraceptive Behavior

Obviously, teens become pregnant because they have sex without effectively using contraception. In the United States, the proportion of teens who have ever had sexual intercourse increases steadily with age. In 1995, among girls, the percentage increased from 25 percent among fifteen-year-olds to 77 percent among nineteen-year-olds, while among males it increased from 27 percent among fifteen-year-olds to 85 percent among nineteen-year-olds. Among students in grades nine through twelve across the United States in 1999, 50 percent reported sexual experience.

Most sexually experienced teenagers use contraception at least part of the time. Condoms and oral contraceptives are the two most common methods, but small and increasing percentages of teens use long-lasting contraceptives such as Depo-Provera or Norplant. Like some adults, however, many sexually active teenagers do not use contraceptives consistently and properly, thereby exposing themselves to risks of pregnancy or sexually transmitted diseases (STDs).

Factors Associated with Sexual Risk-Taking and Pregnancy

While nearly all youth are at risk of engaging in sex and thus girls becoming pregnant, many risk and protective factors distinguish between youth who engage in unprotected sex and sometimes become pregnant and those who do not. For example, when teens have permissive attitudes toward premarital sex, lack confidence to avoid sex or to use contraception consistently, lack adequate knowledge about contraception, have negative attitudes toward contraception, and are ambivalent about pregnancy and childbearing, then they are more likely to engage in sex without contraception.

Other more indirect environmental factors, however, also affect teen sexual risk-taking, either by decreasing motivation to avoid sex or through other mechanisms. For example, teens are more likely to engage in unprotected sex and become pregnant (1) when they live in communities with lower levels of education, employment, and income and thereby have fewer opportunities and encouragement for advanced education and careers; (2) when their parents also have low levels of education and income;(3) when they live with only one or neither biological parent and believe they have little parental support; (4) when they feel disconnected from their parents or are inappropriately supervised or monitored by their parents; (5) when they have friends who obtain poor grades and engage in nonnormative behaviors; and (6) when they believe their peers are having sex and are failing to use contraceptives consistently.

Furthermore, teens are more likely to engage in sex when they, themselves, (1) do poorly in school and lack plans for higher education; (2) use alcohol and drugs, engage in other problem or risk-taking behaviors, and are depressed; (3) begin dating at an early age, go steady at an early age, have a large number of romantic partners, or have a romantic partner three or more years older (the latter being a particularly telling factor); or (4) were previously sexually abused. These individual and environmental, sexual and nonsexual, risk and protective factors are the factors that programs try to change when they attempt to reduce teen sexual risk-taking and pregnancy.

Family Planning Services

The efforts most directly involved with preventing pregnancy among sexually experienced teens are family planning services. The primary objectives of family planning clinics or family planning services within other health settings are to provide contraception and other reproductive health services and to provide patients with the knowledge and skills to use their selected methods of contraception.

Large numbers of sexually active female teenagers obtain family planning services each year. Many of these young women receive oral contraceptives and to a lesser extent other contraceptives that are more effective than condoms or other non-prescription contraceptives. Accordingly, these family planning services prevent large numbers of adolescent pregnancies.

In addition to those practicing at family planning clinics, some clinicians in health clinics also focus upon the adolescent's sexual behavior. Several studies have found that these visits can increase contraceptive use when clinicians spend more time focusing upon the teen patients' sexual behavior; give a clear message about always using protection against pregnancy and STDs; show videos or provide pamphlets and other materials; discuss patients' barriers to avoiding sex or using contraception; and model ways to avoid sex or use condoms or contraception.

Sex and HIV Education Programs

To reduce teen pregnancy and also STDs, including HIV, most schools have implemented sex and HIV education programs. Typically, these programs emphasize that abstinence is the safest method of avoiding pregnancy and STD, but they also encourage condom and contraceptive use if teens do have sex. Contrary to the fears of some people, a large number of studies have demonstrated that these programs do not have negative behavioral effects, such as increasing sexual behavior. To the contrary, many studies have demonstrated that some, but not all of these programs, delay the initiation of sex, decrease the frequency of sex, and increase the use of contraception once youth have sex. They thereby reduce risk of pregnancy, as well as STD. Some sex and HIV education programs have been found to be effective in multiple states in the country, and some have found positive behavioral effects for almost three years.

Programs that are short and that focus upon knowledge increase knowledge, but they tend not to change behavior. In contrast, programs that effectively reduce sexual risk-taking (1) focus on changing specific sexual or contraceptive behaviors; (2) are based on health theories that specify the risk and protective factors to be addressed by the program;(3) give a clear message about avoiding unprotected sex; (4) provide basic, accurate information about the risks of teen sexual activity and about methods of avoiding intercourse or using contraception; (5) address social pressures that influence sexual behavior; (6) provide modeling and practice of communication, negotiation, and refusal skills; (7) employ a variety of teaching methods designed to involve the participants and help them personalize the information; (8) are appropriate to the age, sexual experience, and culture of the participants; (9) last a sufficient length of time to complete important activities adequately; and (10) select teachers or peer leaders who believe in the program they are implementing and then provide them with training.

Many people have proposed abstinence-only programs as a solution to reducing teen pregnancy and STDs. Such programs emphasize that abstinence is the only acceptable method of avoiding pregnancy, and they either fail to discuss contraception or emphasis its limitations. Although some abstinence-only programs might delay sex, there is thus far simply too little research to know which abstinence-only programs are effective.

In an effort to reduce teen pregnancy and STDs, including HIV, hundreds of high schools have made condoms available or have opened school-based health centers that provide reproductive health services. Although studies have demonstrated that these services do not increase teen sexual behavior, they have also found inconsistent results on improved contraceptive use.

Service-Learning Programs

Whereas the programs summarized above focus primarily on changing the sexual risk factors of adolescent sexual behavior, some programs focus primarily on the nonsexual risk and protective factors. In 1997 researchers Joseph P. Allen and associates found the strongest evidence for teen pregnancy reduction for one type of program, service learning.

By definition, service-learning programs include voluntary or unpaid service in the community (e.g., tutoring, working in nursing homes, helping fix up recreation areas) and structured time for preparation and reflection before, during, and after service (e.g., group discussions, journal writing, composing short papers). Often the service is voluntary, but sometimes it is prearranged as part of a class.

Although service learning does have strong evidence for reducing teen pregnancy, other youth development programs have not reduced teen pregnancy or childbearing (e.g., the Conservation and Youth Service Corps, the Job Corps, JOBSTART). Thus, it remains unclear why some programs are effective and others are not.

Comprehensive and Intensive Programs

A few programs designed to reduce teen pregnancy have been designed for high-risk youth and are both intensive and comprehensive. One of them, the Children's Aid Society Carrera program, is an intensive program operating five days per week and lasting throughout high school. It includes family life and sex education, medical care including reproductive health services, individual academic assessment and tutoring, a job club, employment, arts, and sports. Research demonstrates that it reduced both pregnancy and birthrates over a three-year period.

Conclusion

Despite declines in the teen pregnancy rate in the United States in the 1990s, teen pregnancy remains an important problem and diminishes the well-being of both teen mothers and their children. Fortunately, by the beginning of the twenty-first century there were a diverse group of programs that were demonstrated to be effective in reducing teen sexual risk-taking or pregnancy. These include reproductive health services and clinic protocols focusing upon patient sexual behavior, sex and HIV education programs, service-learning programs, and intensive and comprehensive programs for higher risk youth. The diversity of these programs increases the choices for communities. To reduce teen pregnancy, communities can replicate much more broadly and with fidelity those programs with the greatest evidence for success with populations similar to their own; replicate more broadly programs incorporating the common qualities of programs effective with populations similar to their own; and design and implement programs that effectively address the important risk and protective factors associated with sexual risk-taking in their communities.