Once called an epidemic, adolescent childbearing continues to be a nagging social and health concern in the United States. Each year, approximately 1 million young women under the age of 20 become pregnant.1 About half a million of these adolescents give birth and another 400 000 obtain elective abortions.2 Bearing children during the teenage years has profound health consequences for both the young mother and her infant. Pregnancy places the adolescent mother at two and a half times the risk for death as nonadolescent mothers, and infants bom to a mother under 15 years of age are more than twice as likely to weigh 2500 g or less at birth and almost three times more likely to die within the first 28 days of life as infants born to older mothers.1
The economic costs to society of adolescent childbearing are staggering. In terms of Aid to Families With Dependent Children, Medicaid, and food stamps, the cost of births to adolescents in 1985 was estimated to be $16.65 billion.3 These estimates do not take into consideration the additional costs of social services, protective services, special education, or job-related education for the young mother. The public costs for a single cohort of infants born to adolescent mothers followed over 20 years were estimated at $5.16 billion.3 These figures included the costs associated with social, education, and health services for the child from birth to 20 years of age, the point at which the young person was considered to be independent, but failed to account for the opportunity costs associated with the loss of labor force productivity.
Although adolescent childbearing is not unique to the United States, US rates are higher than those found in most developed countries. Compared with Canada, France, the Netherlands, Great Britain, and Sweden, the United States has higher rates of adolescent pregnancies, births, and elective abortions, despite comparable levels of sexual activity.4 For example, in 1987, Canada reported the birth rate for 15 to 17 year olds at 24-9 per 1000 females5 compared with 33.8 per 1000 females for 15 to 17 year olds in the United States.2 Researchers cite poor contraceptive use as the primary reason for high pregnancy rates. With 18% of US adolescents sexually active before age 15 and 66% active by age 19, but only one third using contraceptives,6 it appears that the United States will retain its number-one ranking in the foreseeable future.
Figure 1. Trends in rates of pregnancy, birth, and abortion among US females ages 15 to 19, 1973 to 1985.2
TRENDS IN ADOLESCENT BIRTHS
Until recently, trends in adolescent childbearing had exhibited slow downward movement. The overall rate of adolescent childbearing in the United States dropped through the late 1970s and leveled off in the 1980s, but is now showing some slight increases.7,8 In addition, the proportion of all births accounted for by adolescents showed a similar decline over the past two decades. These overall trends can be misleading if taken at face value. For example, much of the initial decline in adolescent birth rates in the 1970s was due to decreased birth rates among 18 and 19 year olds, the group of teens with the best pregnancy outcomes. Their birth rates dropped from 114.7 births per 1000 females in 1970 to 81.7 births per 1000 females in 1980 and have changed little since then.2 In contrast, after showing a steady decline since the 1970s, birth rates in 1988 among 10 to 14 year olds and 15 to 17 year olds were at their highest levels in the past decade.2 Reductions in numbers of births to adolescents tended to coincide with declines in the US adolescent population. Between 1980 and 1984, the numbers of adolescents who were 15 to 19 years old declined by 11.4%.9 Thus, despite little change in adolescent pregnancy rates, the proportion of births accounted for by teenagers has dropped, in part because there are fewer adolescents than there were a decade ago and because women who delayed childbearing into their 30s are now having babies.
Figure 1 displays trends in pregnancy rates, birth rates, and abortion rates from 1973 to 1985. Since the 1980s, there has been little change in the rates or in their relationships to one another.
CHARACTERISTICS OF ADOLESCENT MOTHERS
The sociodemographic characteristics of adolescents who become mothers has changed markedly over the past two decades, with significant increases in the proportion of adolescent births that occur outside of marriage. Almost two thirds of the adolescents who gave birth in 1988 were single mothers compared with one fifth of adolescents who gave birth in I960.2 There are large racial differences in nonmarital births. More than 90% of births among black adolescents occurred outside of marriage compared with about half of the births to white adolescents.1 Figure 2 shows that the percentage of births outside of marriage to adolescents more than doubled from 1960 to 1970 and has doubled again since then.
Figure 2. Trends in nonmarital childbearing among US females under age 20, 1960 to 1988.2
What accounts for the increase in nonmarital births among adolescents is a much debated topic among social scientists. If there is disagreement over its etiology, there is some consensus as to its consequences for adolescents. Single teen mothers and their children face diminished educational and economic opportunities when compared with other mothers.10 Although many adolescents who drop out of school because of childbearing go on to complete their high school education, the average educational attainment for adolescent mothers is less than that of young women who delay childbearing until their 20s. For example, in 1986, approximately 77% of white and 73% of black 20- to 24-year-old mothers had completed 12 or more years of education compared with 60% of white and 63% of black 19-year-old mothers.11
Nonmarital childbearing has been associated with welfare dependence and poverty12 that may persist for generations. Findings from analyses of the 1988 National Survey of Family Growth data indicate that daughters of both black and white adolescent mothers had a significantly higher risk of adolescent childbearing than daughters of older mothers.13 The social and economic consequences of single motherhood appear more profound than they did a generation ago. In a 20-year follow-up of black urban adolescent mothers, Furstenberg et al14 found that second-generation adolescent mothers (children of the original study population) had poorer educational and financial prospects than did their mothers at the same age. Although the majority of the children of adolescent mothers in the Furstenburg study did not begin childbearing in their teens, those who repeated their mothers' pattern of early childbearing faced a bleak future with the risk of long-term welfare dependence.
Because mothers with first birth during their teenage years are more likely than other mothers to raise their children in impoverished conditions, the children of adolescent mothers grow up in families with limited financial resources, have few opportunities for upward mobility, and may have limited incentives to avoid adolescent parenthood. The perceived opportunity costs associated with an early birth may be diminished among poor youth who have low aspirations and see few viable career options of worth.15 Neighborhoods where early childbearing is the norm rather than the exception are environments conducive to adolescent pregnancy16 because they provide role models of teenagers who became pregnant outside of marriage. Early childbearing in these communities may be part of an alternative life-course response to environmental constraints.17 Increasingly, the role of social contexts, neighborhoods, families, and schools are being considered in studies of adolescent pregnancy.16,18
The proportion of all pregnancies to adolescents 15 to 19 years of age ending in an abortion has risen from 29% in 1974 to 42% in 1985.19 Most of the increase took place in the 1970s and has leveled off since 1980. Racial differences in abortion rates are the result of higher pregnancy rates among black adolescents.20 The proportions of black and white pregnant adolescents who obtain abortions are comparable.20 Adolescents who decide to terminate their pregnancy differ from adolescents who give birth in a variety of ways that contribute to better social and economic futures. They are more likely than teens who give birth to be doing well in school, to not have dropped out of school, to have higher educational aspirations, and to come from families of higher socioeconomic status.7,21,22
Unmarried adolescents are more likely to seek an abortion than those married during pregnancy. In 1984, 6% of the adolescents who obtained abortions were married.2
SEXUAL ACTIVITY AND CONTRACEPTION USE
More adolescents are reporting sexual activity and at younger ages than they did 20 years ago. Since the 1970s, the proportion of teens who report having had sexual intercourse has been steadily increasing. For females ages 15 to 19 years, 26.6% reported having had sexual intercourse in 1970. By 1975, that percentage had increased to 36.4%, and rose to 42% in 1980, to 44.1% in 1985, and to 51.5% in 1988.2 The largest increases in the percentages of adolescent females who report sexual activity have occuned among the youngest ages, from 4.6% in 1970 to 25.6% in 1988 among 15 year olds.2 There are no comparable trend data for adolescent males. The most recent data from the 1988 National Survey of Adolescent Males indicated that 64% of males 15 to 18 years of age had sexual intercourse at least once.2
Despite their increased risk of pregnancy, sexually active adolescents are slow to adopt contraceptive methods. Data from Baltimore family planning clinics indicate that on average adolescents initiate contraceptive use about 1 year after the onset of sexual intercourse.23 Teenagers seen at family planning clinics cite fears that their visit will be disclosed to their parents, fear of pelvic examinations, and fear of health consequences of the pill as primary reasons for delay.23
Contraceptive use rates have increased over the past decade but hafve not kept pace with the numbers of young people who engage in sexual intercourse. For example, in 1988, 78.8% of 15 to 19 year olds who were sexually experienced reported use of a contraceptive method. This contrasts with 71% of the same age group in 1982.2 These overall changes in contraceptive rate use mask important age differences. Younger adolescents are significantly less likely than older teens to use contraceptives.24 Adolescents who are consistent contraceptive users differ in other important ways from those sexually active adolescents who fail to use contraception or who use a contraceptive method sporadically. Consistent contraceptive users are more likely than their sexually active peers to be in stable relationships, to have high educational expectations, and to experience academic success in school.7 These findings suggest that adolescents who perceive opportunities for success are motivated to prevent pregnancy.
What are the implications of these findings for practicing pediatricians? First, pediatricians need to be informed in the often raucous public debates over these issues. There is no "epidemic" of teenage pregnancy. There is no reason to be swept up in the popular notion that sexuality among adolescents is the cause of society's major ills. What is of concern is that the downward trend in adolescent childbearing that started in the 1970s has slowed and most recently has shown an upturn among the youngest adolescents. Furthermore, adolescents are becoming sexually active at younger ages, and it is this very group of adolescents who appear to be at increasing risks for adolescent childbearing because of their poor contraceptive use. Public policy needs to focus on the prevention of unwanted pregnancy among adolescents. Because sexual activity levels among US adolescents are not different from teenagers in major European countries and yet the US rates of adolescent pregnancy, births, and abortions are so much higher we are doing a poor job of pregnancy prevention. Pediatricians need to be well informed and encourage accurate discussion on educating youth about sexuality and promoting access to contraception. While these issues are controversial and involve strongly held ethical and religious views, the debates need to be well informed.
Second, there do not appear to be any benefits to early childbearing, particularly considering the negative social consequences for the adolescent mother. However, teen pregnancy does not "explain" the infant mortality problem in the United States. Even if adolescents had the same pregnancy outcomes as older women, there would be little reduction in the overall rate of infant mortality because the prevalence of adolescent childbearing is not high enough to significantly affect the overall US rate of infant death.
Finally, pediatricians have the opportunity to integrate a focus on issues of sexuality into the care of their patients, male and female. Only recently has deliberate attention been paid to the role young men play in preventing pregnancies.25 Adolescent males are often left out of pregnancy prevention programs that are clinic-based because they are reluctant to seek contraceptives provided in traditional family planning settings. By including discussions of sexuality and contraceptives as part of preventive child care in pediatric office settings, physicians have the opportunity to diffuse some of the sensitivity surrounding adolescent sexual behavior and can potentially impact early childbearing.
The preparation of this article was supported in part by grant no. MCJ-000 106 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, US Department of Health and Human Services.
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