A Model for Increasing Access: Teenage Pregnancy Prevention

136 Presentation A MODEL FOR INCREASING ACCESS: TEENAGE PREGNANCY PREVENTION HENRY W. FOSTER, Jr., M.D. LORRAINE WILLIAMS GREENE, Ph.D. M. SHELTON SMITH, Ph.D. Department of Obstetrics and Gynecology Meharry Medical College Inappropriate teen pregnancy has become a major social issue in this country. The point of emergence of this problem is not clear. However, the single publication that seemed to galvanize awareness of this national dilemma appeared in 1976.1 This article, "Eleven Million Teenagers: What Can Be Done About the Epidemic of Adolescent Pregnancies in the United States," jolted the nation into realizing the magnitude of the problem. Although birth rates for females less than 20 years of age declined during the 1970s, adolescent pregnancy remains an overwhelming problem.*3 More than one million teenage pregnancies, most of them unplanned, will occur in our country this year, with nearly 500,000 births. The United States ingloriously leads all other western nations in this category by nearly a two-fold margin.3 This is a problem that affects all ethnic, social, and economic classes. Discounting the non-white contribution to our nation's teenage pregnancy and birth rates does not change our statistical ranking relative to other western nations. It has been incorrectly presumed that other western nations have lower birth rates than the United States because of their higher abortion rates. In fact, abortion rates in the United States are substantially higher than those for other western countries.* Additionally, in Sweden and France, teenagers become sexually active at an earlier age than do teenagers in our country, yet their pregnancy rates remain substantially lower than ours. The adverse human and economic consequences of teen pregnancies are enormous. Higher school drop-out rates, subsequent unplanned pregnancies, and reduced marketable skills are all likely consequences for teenagers who become pregnant. According to one study, the estimated single-year direct cost to the public of teenage pregnancy in 1985 was $16.65 billion.5 This study also found that if all teenage births were delayed until age 20 or later, the potential Journal of Health Care for the Poor and Underserved, Vol. 1, No. 1, Summer 1990 Foster, Greene, and Smith 137 savings to the public would be $2.06 billion for the entire cohort of teenagers who would otherwise have had a first birth in 1985. The human and economic consequences of unintended childbearing are evident. This is particularly true for certain teenagers. Poor perinatal outcome is more closely associated with low socioeconomic status (SES), poor antenatal nutrition, poor general health, and drug use than with maternal age.6,7 In a recent review, researchers concluded that there is a relationship between poverty and poor reproductive status.8 Moreover, it has been acknowledged that adolescent parents tend to come from high-risk families.5 Clearly, our incidence of teen childbearing is unacceptably high. Innovative approaches must be created and applied to seek some redress from this problem. Rationale for program design It is apparent from the continuing high rates of teen pregnancy in this country that previous efforts to attack this problem are wanting. In a preliminary report to the Rockefeller Foundation, Dryfoos observed that strategies for pregnancy prevention programs, particularly for adolescents, historically tend to follow one of three general approaches: to (1) impart knowledge, (2) provide access to contraception, or (3) enhance life options.9 Clearly, there is some overlap, but most programs stress one of these approaches. Despite agreement that American youth need knowledge about human reproduction in order to act responsibly in matters of sexuality, there are, nonetheless, continuing barriers to the availability of this education, and indeed conflicting studies as to its value.10"12 However, the literature does show that sex education programs are most likely to be effective when actively coupled with direct access to contraceptives. Reciprocally, it stands to reason that the effectiveness of predominantly service programs will be decreased if not coupled with sex education. The "newcomers" on the block are programs that focus on the enhancement of life options by strengthening adolescents' self-esteem. An awardwinning series by Washington Post reporter Leon Dash clearly shows that the capacity to prevent pregnancy without the desire to prevent it is...