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What Is to Be Done about the Rise in Teen Childbearing?

2009; Elsevier BV; Volume: 45; Issue: 1 Linguagem: Inglês

10.1016/j.jadohealth.2009.04.013

1879-1972

Sarah Brown, Katherine Suellentrop,

Child and Adolescent Health

See Related Article p. 25 See Related Article p. 25 The article by Santelli and colleagues [[1]Santelli J.S. Orr M. Lindberg L.D. Diaz D.C. Changing behavioral risk for pregnancy among high school students in the United States, 1991–2007.J Adolesc Health. 2009; 45: 25-32Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar] in this issue of the Journal shines a spotlight on an enduring American challenge: adolescent childbearing. After well over a decade of progress, the Centers for Disease Control and Prevention recently announced that for the second year in a row, the nation's teen birth rate (TBR) increased. Between 2005 and 2006, a 3.5% increase was noted; for the 2006 to 2007 interval, the increase was 1.4%, suggesting that what began as a 1-year uptick may have become a trend. This discouraging news reversed a decline in teen births that began in 1991 when the TBR was 61.8; by 2005 it had decreased to 40.5 [[2]Hamilton B.E. Martin J.A. Ventura S.J. Births: Preliminary Data for 2007. National Vital Statistics Reports, vol. 57, no 12. National Center for Health Statistics, Hyattsville, MD2009Google Scholar]. The authors do note that abortion does not appear to be an important factor in the recent changes in the TBR, which is a point worth stressing. Many of us who follow these rates and trends carefully wondered aloud if perhaps one of the great public health successes in recent years had come to a grinding halt [[3]Moore K.A. Teen Births: Examining the Recent Increase. The National Campaign to Prevent Teen and Unplanned Pregnancy and Child Trends, Inc., Washington, DC2008Google Scholar]. We also noted that even though we had been delighted with years of declines in both teen pregnancy and birth, the United States still has the highest rate of teen childbearing among comparable countries [[4]Jones E.F. Forrest J.D. Goldman N. et al.Teenage Pregnancy in Industrialized Countries. Yale University Press, New Haven, CT1986Google Scholar]. In fact, at present, 30% of U.S. teen girls get pregnant at least once before their 20th birthday; for African American and Hispanic teen girls, the numbers are even higher—51% and 53%, respectively [5National Campaign special tabulations of Ventura S.J. Abma J.A. Mosher W.D. Henshaw S.K. Estimated Pregnancy Rates by Outcome for the United States, 1990–2004. National Vital Statistics Reports, vol. 56, no 15. National Center for Health Statistics, Hyattsville, MD2008Google Scholar, 5aMartin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S. Births: Final Data for 2004. National Vital Statistics Reports, vol. 55, no 1. Hyattsville, MD: National Center for Health Statistics, 2006.Google Scholar]. The recent increases also offered an opportunity to again explain why teen childbearing is of such concern. Its close association with poverty and single parenthood burden both the teen mother and her child, and the precarious state of today's economy exacerbates the risk [[6]Hoffman S.D. Maynard R.A. Kids Having Kids: Economic Costs and Social Consequences of Teen Pregnancy. 2nd ed. Urban Institute Press, Washington, DC2008Google Scholar]. Securing a well-paying job in the U.S. employment market has become tougher on all fronts, but especially for those with limited education [[7]Danziger S. Earnings by Education for Young Workers, 1975 & 2002. Data Brief, issue 17. Network to Transitions on Adulthood, Philadelphia, PA2004Google Scholar]. Many national leaders, including President Obama, now speak about the need to complete not only a high school education but at least 2 years of additional training as well [[8]Obama B. Address to Joint Session of Congress February 24, 2009. Available at: http://www.whitehouse.gov/the_press_office/Fact-Sheet-Expanding-the-Promise-of-Education-in-America/. Accessed April 16, 2009.Google Scholar]. Because of the compelling need for young people to postpone family formation until well beyond the teen years, it is increasingly important for us to understand what drives changes in rates of adolescent childbearing and what might happen in the future. Santelli and his colleagues [[1]Santelli J.S. Orr M. Lindberg L.D. Diaz D.C. Changing behavioral risk for pregnancy among high school students in the United States, 1991–2007.J Adolesc Health. 2009; 45: 25-32Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar] explore both. Using data from the Youth Risk Behavior Survey (YRBS), they developed a pregnancy risk index (PRI) based on a teen girl's sexual activity and contraceptive use. The PRI incorporates information from the YRBS on sexual activity in the past 3 months, contraceptive method used at last sex, and method-specific failure rates. Based on birth data available through 2006 and pregnancy data available through 2004, the investigators were able to validate the PRI and determine that it was highly correlated with actual pregnancy and birth rates for teens age 15 to 19. That is, the predictive model fits reality—no small achievement, especially given that the increases in the TBR have been concentrated among 18- and 19-year-olds, and the YRBS captures few of these older teens. The researchers also determined that between 1991 and 2007, behavioral risk for pregnancy among high school students declined, but virtually the entire decline occurred between 1991 and 2003. Between 2003 and 2007, a borderline increase in pregnancy risk among sexually active teens suggests that they are slightly less likely to use an effective method of contraception. Based on such data, the authors predicted that the increase in the TBR from 2005 to 2006 might be followed by a second year of increase as well. As already noted, they were correct. Even if the TBR does not increase again, the behavioral data suggest that at best it will remain at its current level, which is, in our view, most unfortunate. The article also points out the complexity of measuring and reporting behavior. Although the proportion of teens who have ever had sex decreased during the late 1990s and beginning of this decade, the proportion of teens who have had sex in the last 3 months (that is, who are sexually active) has stayed relatively stable [1Santelli J.S. Orr M. Lindberg L.D. Diaz D.C. Changing behavioral risk for pregnancy among high school students in the United States, 1991–2007.J Adolesc Health. 2009; 45: 25-32Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 9Balaji A. Lowry R. Brener N. et al.Trends in HIV- and STD-related risk behaviors among high school students—United States, 1991–2007.MMWR. 2008; 57: 817-822PubMed Google Scholar]. This finding also highlights the importance of accurate and consistent contraceptive use among sexually active teens. As we often point out, only those teens who are having sex and are not adequately protected by contraception are getting pregnant. The key question, of course, is how to return to a steadily decreasing rate of teen childbearing—or, preferably, a steadily decreasing rate of teen pregnancy. Santelli et al [[1]Santelli J.S. Orr M. Lindberg L.D. Diaz D.C. Changing behavioral risk for pregnancy among high school students in the United States, 1991–2007.J Adolesc Health. 2009; 45: 25-32Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar] call for more sex education and health services (presumably family planning services), along with a national conversation about the importance of preventing unplanned pregnancy and sexually transmitted diseases (STDs) as well. These are reasonable suggestions, and data suggest that services and education, in particular, will help [[10]Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases. The National Campaign to Prevent Teen and Unplanned Pregnancy, Washington, DC2007Google Scholar]. But we should do more. We need to talk with teens as much about relationships as we do about reducing the risk of pregnancy and STDs. All of us probably agree that current popular culture which teens attend to with great intensity, particularly media and celebrity culture, is remarkably crude, and often shows sex as having little meaning and few consequences. Commitment, caring, and contraception are often the exception, and teen childbearing is frequently portrayed as fully acceptable if not actually glamorous (think Juno and Jamie Lynne Spears). Our national conversation must also address the growth in nonmarital childbearing, which surely forms the broader context within which teen childbearing occurs. At present, 40% of all babies are born to unmarried women, and for women 20 to 24—the older sisters and friends of teens—the latest figure is 60% [[2]Hamilton B.E. Martin J.A. Ventura S.J. Births: Preliminary Data for 2007. National Vital Statistics Reports, vol. 57, no 12. National Center for Health Statistics, Hyattsville, MD2009Google Scholar]. Are we to call for less teen childbearing but be completely silent on nonmarital child bearing? We should also consider reviving some old ideas and normative statements that one rarely hears anymore—many of which might help teens understand more deeply why so many adults recommend that they delay starting families. Here are a few:•Babies and children are more likely to thrive when they are raised by adult parents who are committed to each other and to years of devoted parenting.•“If it happens, it happens” is no way to start a family. And “I never really thought about it” isn't either.•Babies do not cement relationships; they often put great stress on them. Be sure you are in a solid relationship before you begin a family.•Sex has meaning, risks, and consequences. It's not a casual activity. Take it seriously.•Babies do not give unconditional love; they demand it from the adults around them.•To boys and men: making babies does not make you a man. Being a devoted partner and father may.•To girls: sex will not make him yours, and a baby will not make him stay. In short, getting pregnant/causing pregnancy and starting families are perhaps the most important things we ever do, with generational effects. These major steps need to be thought about carefully, not stumbled into. We think and talk about so many less important things all the time: what's for dinner, the upcoming World Series, what movie to see this weekend… Surely the issue of when to become a parent, with whom, and under what circumstances deserves at least the same amount of time and attention. This is more than sex education or risk reduction; it's education for adult life, and we do not do enough of it.