Special Issue: Adolescent Pregnancy: Past, Present and Future Trends and Issues

The dramatic overall decrease in rates of pregnancies and births to American teenagers over the last few decades should be counted among contemporary success stories in systematic efforts to reduce bio-psychosocial risks to youth. Since the modern peak in 1991, fertility among all major racial and ethnic groups of teens has, with a few brief reversals, steadily and sharply declined: births by about 64% and pregnancies 55% [1]. Though the rate of births to teens remains among the highest in developed nations, approaching twice that of the next-highest, the U.K., the consistency of the trends suggests that the modern tide of high-risk sexual activity associated with unplanned conception among ever-younger American youth has been at least somewhat curtailed [1].

While we see broad changes in young people’s sexual behavior that resulted in reduced risk overall of unplanned pregnancy and childbearing, continuing stark disparities in the incidence of early pregnancy among adolescents reveal the profound impact of social and economic inequality on youth’s wellbeing in American society. For example, despite within-group declines, Latinas, African American and Native American girls continue to face disproportionate risk of pregnancy; births to teens in impoverished rural areas have risen sharply; and girls in foster care are twice as likely to give birth as those in the general population [2,3]. The clear association of teen pregnancy and childbearing with the complex dimensions of disadvantage led Sarah Brown, former Director of the National Campaign to Prevent Teen and Unplanned Pregnancy to observe that we may already have achieved the “easy wins” in bringing down rates of pregnancy and childbearing among American adolescents [2].

After several years of significant public investments in reducing fertility among teenagers though research, policy, services, and education, the result is that more teens are delaying sexual initiation; many teens are less sexually active; more of those teens who do have sex use contraception effectively; and many of those teens who become pregnant have abortions. Though there remain both empirically- and ideologically-based debates over the relative value of abstinence-only interventions and comprehensive sex education, research suggests that many teenage pregnancy prevention programs are quite effective, and that some programs are more effective for certain teens than for others. That is, if we employ a comprehensive and multi-faceted rather than one-size-fits-all strategy to preventing teen pregnancy, we have significant impact on diverse youth’s sexual behavior.

The largest proportion of adolescents falls into whom Brown includes as the “easy wins”. In other words, the category of youth who were, and remain, at lowest risk of early conception have benefitted most from efforts at teen pregnancy prevention, while others at higher risk will require interventions that target more closely the particular sources of their vulnerability.

Most American teenagers are unlikely to become parents because they do not possess the many environmental and individual risk factors associated with engaging in early and unprotected sex. They face the challenges of negotiating cultural expectations for decision-making in important behavioral arenas such as sexuality typically with normal developmental limitations in cognitive processing and the emotional maturity that are necessary to meet those expectations wisely, and lack of access to contraception and other sexual health services. However, for these low-risk youth the realistic possibility of educational and occupational success generally provides sufficient motivation to avoid young parenthood when they possess the requisite knowledge, skills, and resources.

At greater risk are teens whose family and individual characteristics are associated with a variety of high-risk behaviors such as drug and alcohol abuse in addition to having unprotected sexual intercourse. They face the same developmental challenges to healthy decision-making as low-risk peers in the context of a highly sexualized socio-cultural environment, but often without strong family and community support and resources that support healthy decision-making. Teens are at greater risk of early pregnancy when they: (1) become sexually active young; (2) have low expectations for, weak attachment to and/or poor performance in school; (3) engage in problem behaviors associated with conduct disorders and other forms of mental health challenges and are easily influenced by similar peers; and (4) do not have strong relationships with parents or guardians [2]. Thus, high-risk sexual activity may reflect a different developmental context for these youth than it does for adolescents at lower risk of unplanned pregnancy.

At the farthest and most worrisome end of the continuum of risk of pregnancy and parenthood are those young people who share few of the attributes of the “easy wins”. They possess the risk factors of teens at lower levels of risk, but face additional hazards to developmental wellbeing generally associated with poverty and other forms of extreme disadvantage. Whether these vulnerable adolescents grow up in impoverished rural or urban communities, or come from families that are struggling with such serious dysfunction that the child welfare system has intervened, they often conceive for a variety of complicated reasons that are difficult to mitigate through the most common approaches to pregnancy prevention. For these most vulnerable youth, whose lives too often are filled with trauma, turmoil, unfilled emotional and other developmental needs arising from family and community patterns that may extend back over generations, the meaning of teen pregnancy is distinct from those teens who most need high quality sexual health services in order to prevent unplanned pregnancy [4].

Given the impressive success in influencing teenagers at low levels of risk to avoid unplanned pregnancy, it is a felicitous time to stand back and examine what accounts for the changes, to assess the current situation, and to establish priorities for continuing efforts to enhance the health and wellbeing of our youth. This collection of papers together addresses these large questions from the perspectives of some of the most seasoned and influential observers in the field, representing a variety of disciplines such as developmental psychology, economics, sociology, education, and social work. These scholars are among the leaders whose research and insight helped shape both knowledge and its application in the national movement to reduce teen pregnancies and births and their consequences in the United States. Their work, while acknowledging that there remain unresolved and challenging questions, reflects the increasingly sophisticated and nuanced approaches to understanding the very meaning of teen pregnancy and childbearing today.

What accounts for the steep decline in overall rates of teen pregnancy over the last few decades? There are, logically, limited means for avoiding conception deliberately, aside from sterilization: abstinence from sexual intercourse or use of contraception. While it is difficult to pinpoint precisely how much each of these changes in behavior contributed to the decline in teen pregnancy and, further, what factors influenced each choice to what degree, there is wide agreement that a significant increase in contraceptive use has played a major role [5]. Beyond the obvious overall impact of contraceptive use per se, there are complex questions regarding specific patterns of use of each form of birth control whose answers are critical for informing practice with sexually active youth. Manlove, Karpilow, Welti, and Thomas examine adolescents’ contraceptive use over time in, “Linking changes in contraceptive use to declines in teen pregnancy rates”. Employing an innovative microsimulation method, they find that about half of the overall decline in rates of teen pregnancy between 2002 and 2010 is the result of changes in contraceptive use, and further specify what individual practices constitute this “contraceptive effect”. Their recommendations for further reduction in teen pregnancy include both targeting the highest-risk teens who do not use birth control and increasing teens’ use of effective methods.

Despite sexually active teens largely becoming more effective at using contraception, the association between growing up disadvantaged and experiencing early pregnancy and childbearing endures. Why is this so, given the greater options for and availability of birth control? What economic and social consequences of early childbearing can rightly be attributed to teen parenthood; what consequences to the predisposing conditions of early and unprotected sexual activity and pregnancy? Early research in the area of teen pregnancy tended to reflect the assumption that that abridged educational achievement, economic independence and similarly compromised life trajectories of their children resulted primarily from the young age of conception. In the course of cultural and economic changes in the larger society and new scholarly insights, there developed more emphasis on teen pregnancy as a “marker” of disadvantage. These overarching issues shaped much of the scholarly discourse—as well as policies and programs—since the era that teen pregnancy was defined as a public problem in the United States in the 1960s. Have the answers to these fundamental questions changed over time? The next several pieces help untangle these multifaceted questions through diverse methodological and theoretical lenses and place them in historical context.

Each bringing to bear his deeply-informed respective scholarly perspective on these issues Saul Hoffman and Frank Furstenberg investigate how causes and consequences of early childbearing have been explained, how accurate these explanations are, and the implications of these conventions for intervention. In, “Teen childbearing and economics: A short history of a 25-year love affair”, Hoffman provides a critical assessment of the strengths and limitations of the major economic theories, such as the widely influential opportunity cost hypothesis, and their associated methods that have informed assumptions about the motivations for and impact of teen births for disadvantaged young women. He examines how the “threads” of rational choice decision-making, empirical evidence undergirding the supposition that teen motherhood caused lifelong and multi-generational disadvantage, and the fact of plummeting rates in teen fertility, all tie together in a concise and coherent account of the intellectual history of scholarship in this area. While his analysis supports the view of teen pregnancy as more marker of than independent contributor to disadvantage, he concludes with the “reasonable” acknowledgement that the weight of scholarship affirms that there is merit to both perspectives and warns of the need for methodological care in reaching firm conclusions.

Taking up a related set of issues in, “Reconsidering teenage pregnancy and parenthood”, Furstenberg reviews what the past 50 or so years of research have shown about the impact of early childbearing on the life course of teen mothers and their children, and what insight that provides about the significance of early motherhood among disadvantaged youth. Drawing on his own seminal longitudinal research in light of wide-ranging additional research, he argues that despite the positive changes in general trends in teen pregnancy, it is the “long shadow of disadvantage” rather than age per se that continues to darken the prospects of young parents and their offspring. Consequently, delaying childbearing alone will not improve the life chances of young mothers and their children unless they also increase their educational and occupational achievement.

There is general agreement among the authors here that the pre-disposing conditions that heighten the likelihood of teen parenthood are also integral factors in the challenges they may face as young adults and thereafter. Nevertheless, despite the strong evidence supporting this shift in perspective over the last several years, the next set of authors remind us that adolescent parents and their offspring face special vulnerabilities not resulting solely from prior life circumstances that must be attended to. In posing the question, “Has adolescent childbearing been eclipsed by nonmarital childbearing?” Anne Martin and Jeanne Brooks-Gunn identify one of the very bases for the problematizing of teen pregnancy—the rise in adolescents bearing children outside of marriage. As the fertility rate among adolescents essentially declined after 1960, so did their rate of non-marital childbearing increase, to over 90% today. However, this significant shift in adolescents’ choices occurred as part of dramatic changes in broader norms of family formation, particularly a steep rise in non-marital childbearing among older women. The authors suggest that in the context of wider attention to the negative economic and other outcomes associated with non-marital childbearing, we may be neglecting several specific difficulties faced by adolescent mothers and their children. They recommend that in order to assess the true impact of early childbearing, as distinct from pre-existing disadvantage, it is important to identify the appropriate comparison group, namely unmarried women in their 20s. Bringing to bear their considerable expertise in understanding the characteristic developmental needs of young mothers and their children, Martin and Brooks-Gunn delineate three compelling areas for further research: the experience of co-residence in three-generation households, the place of biological and social fathers of teens’ children, and the nature of their childcare choices, all of which constitute noteworthy ongoing problems for teen mothers.

Continuing the volume’s theme of the continuing challenge in discerning which risks precede and which may follow early childbearing, Jacqueline Corcoran reviews the literature on, “Teenage pregnancy and mental health”. She focuses on two of the most prevalent mental disorders experienced by pregnant and parenting teens, depression and conduct disorders. While it is difficult to separate definitively the pre-existing factors that would elevate the risk for mental disorders among disadvantaged youth as distinct from the stresses of pregnancy and childbearing, the association is clear: Adolescents living in poverty and who experience multiple adverse childhood events also are vulnerable to depression, conduct disorder, and early pregnancy. Concluding that it is crucial to understand the etiology of these mental health problems in their full environmental complexity and intervene accordingly, Corcoran also identifies the best practice models focusing on family treatment.

Widening the geographic lens on what constitutes risk of early pregnancy to a hitherto unexamined Southeast Asian cultural context, Nguyen, Shiu, and Farber report on fertility trends in, “Prevalence and factors associated with teen pregnancy in Vietnam: Results from two national surveys”. Providing a comparison between two very disparate cultures with distinct socio-political histories, their findings from a nationally representative sample over time reveal some themes similar to those in the United States. However, they also highlight the need for cultural specificity and consideration of the social and historical factors in analyzing the meaning of early childbearing in a developing nation undergoing rapid transformation.

Next, Decker, Berglas, and Brindis focus closely on two major themes of this collection in emphasizing the importance of providing reproductive health services, with special attention to the most vulnerable youth. In, “A call to action: Developing and strengthening new strategies to promote adolescent sexual health”, the authors analyze the specific ways in which the complex lives of both special populations of youth and their general counterparts require new approaches to enhancing their sexual health. Synthesizing findings from their comprehensive review of recent research, they suggest six “promising strategies” that incorporate programmatic innovations and respond to the particular needs of diverse young men and women. Together these strategies incorporate attention to policies, services, education and individual factors, and recognition of the potential power of using technology to enhance adolescents’ sexual health. This far-reaching blueprint provides a basis for establishing priorities in designing multi-level sexual health services to adolescents.

The final two articles focus on the central importance of improved research methods over the past several decades of prevention efforts. Susan Philliber recounts how increasing methodological rigor in process and outcome evaluation research has been inextricably connected with governmental and other formal organizational standards and investments in improving knowledge from evaluation science. Reflecting on lessons from her long experience conducting evaluation research, she finds significant progress in scientists’ ability to measure the impact of interventions, but reminds us of the remaining challenges of “real world” research especially related to recruiting the most at-risk youth, data collection, randomization, and loss to follow-up.

Finally, as an example of the growing expectations of methodological sophistication in evaluation research in adolescent sexual behavior, Walker reports significant findings from one study suggesting the importance of ethnic identity as a factor in program impact. She notes the complexity in developing a trustworthy knowledge base by drawing attention to the continuing problem that attrition poses to the development of reliable and valid conclusions about behavior change.

The convergence of concerted efforts to reduce teenage pregnancy and childbearing with the shifts in complex social, cultural and health-related norms have reduced the risk of many young women and men of unplanned conception and parenthood. While we must gratefully acknowledge these major positive changes, the clear lesson proffered here is that further reductions may be even more difficult because they require no less than mitigating the worst threats to child wellbeing and optimal development today in American society. However, the contributions of the senior scholars here provide balanced and deeply-grounded perspective necessary to guide the next chapter in fulfilling our collective responsibility to ensure the wellbeing of our young people.