Teen Pregnancy

T he subject of teen pregnancy is frequently covered in major newspapers and magazines. The impression made by dramatic headlines is one of irresponsible, sex- crazed young people engaging in promiscuous, unprotected sex leading to an “epidemic” of teen pregnancies. These articles, as well as current government, insurance industry, and educational policies related to teen pregnancy, often ignore sound science and public health and are marred by misinformation, religious zealotry, simplistic and unworkable solutions, and prejudice and “victim blaming.” 

Teen pregnancy rates are decreasing . Greater than 50 percent of high school-age adolescents are sexually active; average age at first intercourse is 17 for girls and 16 for boys.  Current birth rates of girls age 15 to 19 (49 births per thousand females) have gradually decreased since 1960. Over the last ten years, the percentage of high school students who have had multiple partners decreased by 24 percent. Up to two-thirds of adolescents use condoms, three times as many as did so in the 1970s. 

Teen pregnancy is linked to poverty . Despite the increased use of birth control, the U.S. has rates of teen pregnancy, which are three to ten times higher than those among the industrialized nations of Western Europe. U.S. teen poverty rates are higher by a similar magnitude. Six out of seven U.S. teen births are to the 40 percent of girls living at or below the poverty level, and more teenage girls are dropping below this level due to Clinton/Bush policies aimed at “reforming” (deforming?) welfare. 

Adult males usually impregnate teenage girls . The role of adult males in teen pregnancy is under-recognized.  In the most comprehensive study to date of males directly responsible for teen pregnancies, conducted in California in 1993, 71 percent of teen pregnancies (for whom a father was reported) were fathered by adult men with an average age of 22.6 years, or 5 years older than the mothers. More births were fathered by men over 25 than by boys under 18. Sexually transmitted disease and acquired immunodeficiency syndrome rates among teenage girls are two to four times higher than among age-matched teenage boys; instead, teenage girls’ rates are closer to adult male rates. Statutory rape, in which adult perpetrators or boyfriends have sexual intercourse with underage girls, is infrequently reported by providers. States are evenly split on whether or not mandated reporting is required.

Lack of access to contraception facilitates teen pregnancy. Only 8 percent of U.S. high schools provide condoms, despite the fact that promotion and distribution of condoms does not increase teen sexual activity. Access to contraception of all types is particularly burdensome for rural teens. Recently, legislation that would prohibit prescribed contraceptives for adolescents without parental involvement was introduced in ten states and the U.S. Congress. A survey of girls younger than 18 seeking services at Planned Parenthood found that mandatory notification for prescribed contraceptives would impede girls’ use of sexual health care services, potentially increasing teen pregnancies and the spread of STDs. 

Across the U.S., many health plans fail to cover all contraceptive methods, even though all methods are more effective and less costly than no method. Many fewer plans cover abortion than cover sterilization, leaving poor women in the unenviable position of having to choose sterilization if they lack the resources for adequate contraception or for an abortion (which may become necessary even when accepted contraceptive methods are used as directed). On a positive note, the U.S. House of Representatives recently voted to reinstate the contraceptive coverage for federal employees that President Bush omitted in his 2002 budget proposal. 

The availability of emergency contraception should help further decrease teen pregnancy rates, especially if it becomes available over-the-counter, as the American Medical Association and the American College of Obstetrics and Gynecology have recommended. Even so, some Catholic hospitals prohibit discussion of emergency contraception, even with rape victims. 

Sex education: the good, the bad, and the ineffective . The vast majority of sex education programs in the U.S. do not affect teenage behavior in any substantial way. They neither promote more sexual activity, nor do they significantly reduce unprotected sex.  The few programs that do work give teenagers a clear and narrow message—delay having sex, but if you have sex, always use a condom. Good programs also teach teens how to resist peer pressure. Unfortunately, “Welfare Reform” legislation allocated states $50 million over 5 years to teach abstinence, rather than to provide contraceptives. In 1988, only 2 percent of U.S. school districts relied solely on abstinence-only sex education programs; by 1999, 23 percent did. 

Abortion is common yet increasingly difficult to obtain . Contrary to occasional media depictions of teens as the main recipients of abortions, 48 percent of those having the procedure are over age 25; 20 percent are married; 56 percent have children.  By age 45, the average female will have had 1.4 unintended pregnancies; 43 percent will have had an induced abortion. Fifty-eight percent of women with unintended pregnancies get pregnant while using birth control. This is not surprising, given one year contraceptive failure rates ranging from 2 to 3 percent for IUDs, to 7 percent for contraceptive pills, to 21 percent for periodic abstinence.  Even so, between 1990 and 2000, the number of annual abortions dropped 18 percent, from 1.6 million to 1.3 million. 

Since the 1973 Roe v. Wade decision legalizing abortion, various barriers have been erected in the path of those seeking to obtain one.  The Hyde Amendment of 1977 cut off Medicaid funding for nearly all abortions.  Before former President Clinton took office, discussion of abortion in federally funded health clinics was prohibited. Thirty-nine states have parental notification laws, which have led to a rise in late trimester abortions and to increased numbers of abortions in neighboring states without such laws. 

Recently, the Bush administration drafted a policy that would let states define unborn children as persons eligible for medical coverage. The current Administration has also introduced bills to increase the $3 million per year already spent on so-called “Crisis Pregnancy Centers,” in which pregnant women are given non-factual information regarding abortion, refused information about contraception, shown an ultrasound of their fetus, and watch a slide show depicting bloody aborted fetuses in which it is claimed that abortion is a leading cause of sterility, deformed children and death. In fact, it is 30 times more dangerous to carry a fetus to term than to undergo a legal abortion. The availability of mifepristone (RU-486) for medical pregnancy termination has the potential to improve women’s access to safe abortion. 

Abortions cost approximately $350; most patients pay out of pocket. Only one out of three patients has insurance coverage, and only one out of three insurance companies cover the procedure after the deductible is met. Thirty- four states provide no Medicaid funding for abortion; of the 16 that provide coverage, most make it available only in cases of fetal abnormality, rape, or when the pregnant woman’s life is endangered or health at risk because of the pregnancy (see “Georgia’s Abortion Bill,” Z Magazine , January 2003). Often patients are reluctant to file claims due to confidentiality concerns. 

Other obstacles to abortion include bans on specific methods, mandated waiting periods, parental and spousal notification laws, regulation of abortion facility locations, zoning ordinances designed to keep abortion clinics from being built in certain areas, and TRAP (Targeted Regulation of Abortion Providers) laws.  Bills already approved by the House of Representatives, and headed for the Republican-majority Senate, include: the Unborn Victims of Violence Act, which gives legal status to a fetus hurt or killed during the commission of a federal crime; the Child Custody Protection Act, which makes it a crime in some cases to transport a minor across state lines for an abortion; and the Abortion Non-Discrimination Act, forbidding state and local government actions against hospitals or health care workers who refuse to participate in abortions. Three recent appointments to the Food and Drug Administration’s Reproductive Health Drugs Advisory Committee, Drs. David Hager, Susan Crockett and Joseph Stanford, are avowed foes of abortion rights. Obstetrician-gynecologist Hager, who has advocated Scripture reading and prayer for premenstrual syndrome, reportedly refuses to provide contraceptives to unmarried woman. 

It is time to approach teen pregnancy with rational public health policies, which acknowledge the myriad social injustices facilitating teen pregnancy, employ methods known to reduce unwanted pregnancies, and aim to improve the health and welfare of teenage mothers and their children. Suggested policies  could include: 

• Early, ongoing, and accurate sex education 
• Enhanced access to reproductive health services, through the enactment of universal coverage and by building, staffing, and providing protection for the staff of reproductive health clinics 
• More comprehensive training of physicians, especially obstetrician-gynecologists, in contraception and abortion 
• Overturning parental notification laws; increasing federal funding for family planning 
• Providing financial and other incentives to support young women who wish to continue their education and to improve the lives of those living in poverty (for example, via enactment of living wage statutes and by bringing women’s salaries into line with those of men having equivalent training and job requirements). 

Success in these endeavors will require the concerted efforts of medical educators, health professionals, teachers, employers, non- governmental organizations, concerned citizens, and our elected representatives.

Martin Donohoe is a senior scholar at the Center for Ethics in Health Care, and Assistant Clinical Professor of Medicine at Oregon Health and Science University.