I am the Director of Neonatology at the University of Cincinnati and Children's Hospital Medical Center in Cincinnati. As such I have experienced the excitement and sadness of working in a newborn intensive care unit, watching over many sick, small infants. Everyday, tiny, premature infants may experience a threat to their lives. These infants may have apnea or bradycardia; they may have to be "stimulated" physically or chemically and given artificial respiration; or they may need to be intubated. After weeks and months of intensive care, the happy day arrives when the child is handed over to ... a 13-yearold mother.
This day is one of the sadder days of a neonatologies life; the last few months of the baby's life have been highly stressful, but they are not comparable to the problems the child will have from this moment onward. The tragedy of teen pregnancy strikes me again and again as I walk through the neonatal intensive care units. Is it every fourth baby or every third baby, whose mother is a teenager? The magnitude of the problem is overwhelming.
A million babies and $20 billion dollars a year - teenage sexual involvement and pregnancy are a national disgrace, a major reason for school dropouts, child abuse, and sexually transmitted diseases; the list goes on and on. What has our society become?
The problem of teen pregnancy has seemed insurmountable. Statistics appeared to be worse each year. In 1989, Pediatrics published an article reporting that five studies showed that even sex education in public schools was not altering sexual practices of young teens.1
We hear confusing statistics about infant survival. We hear of the tremendous advances in neonatology, and how we can save extremely small infants. We hear reports of 1-kg to 1.5-kg infants whose survival is now 95% 12 And in the United States, we certainly have some of the most sophisticated technology in the world to salvage very sick, small babies. Yet, in the same breath, we say that infant survival in the United States is 20th worldwide.3 Twentieth? It seems such a contradiction. Yet what is happening is that our sociologie problems have overwhelmed our technologic advances. The single most important factor in neonatal mortality in the United States is now low-birth-weight infants. Low-birth-weight infants are 50 times more likely to die than normal-weight infants - a 5000% increase! And it has been estimated that 24% of all low-birth-weight infants in the United States are bom to teenage mothers.4 If teenage pregnancy could be prevented, it would be a significant contributor toward reducing our infant mortality.
And what is the cause of teenage pregnancy? James Dobson of the University of Southern California says, "adolescents mature sexually at least 4 to 5 years before they reach emotional maturity. Thus, most 15-year-olds would not know a meaningful relationship if they faced one in broad daylight. They lose all objectivity when influenced by a full moon - or a strong rock beat - or a well-endowed partner. They are madly in love for at least 12 hours."5 Biology.
Sol Gordon, author of Raising Your Child Conservatively in a Sexually Permissive World, says, "Few boys ever have sex spontaneously; they are planning, organizing, and thinking about this for some time."6 Biology.
Miller and Olson reported in 1988 that early dating habits predict early sexual involvement. Dating at the age of 12 years is associated with a 91% chance of being sexually involved before the end of school, and dating by age 13 years is associated with 56% involvement.7 Culture.
Time has reported that in the course of a year, the average viewer sees more than 9000 scenes of suggested sexual intercourse or innuendo on prime time TV (Time. December 9, 1985:76-90). Nine thousand! Culture. Are biology and culture conspiring to drive our children inevitably into early sexual involvement?
However, there is some reason for hope, as described especially in this issue of Pediatric Annals by Jim Stout and Marion Howard. Dr Stout describes the four generations of programs directed toward alteration of teenage sexual practices.8 He concludes that the fourth-generation programs are now showing results of significant alterations in sexual behavior.
For example, an ambitious project by the University of South Carolina was conducted from October 1982 to September 1987.9 Murray Vincent and coworkers saturated a rural community with large quantities of pregnancy prevention messages. These intervention messages were targeted at parents, teachers, ministers, community leaders, and children in the public school system. The message emphasized the development of decision-making and communication skills, selfesteem enhancement, and understanding human reproductive anatomy, physiology, and contraception. In the intervention portion of the program, there was a marked drop in expected pregnancy rates, compared with three other counties, whose statistics went their expected path - upward.
Another program introduced in the Atlanta schools by Marion Howard of Emory University is entitled Postponing Sexual Involvement and is discussed in more detail in her article in this issue of Pediatric Annals.10 An important feature of this program appears to be that it uses junior and senior high school students to be the role models and teachers for eighth-grade students. In Cincinnati, after a 4-year preparation period, this program was introduced in the seventh grade of six public schools. During the 1991 to 1992 school year, all public schools in Cincinnati implemented this program, reaching 4000 students in 18 public schools. Juniors and seniors who are teachers are carefully selected: they are chosen from the ranks of those admired school-wide, and they must be able to communicate the abstinence message clearly. It has been impressive to see these young people at work and to see how seventh graders look up to them. As expected, teens listen to other teens.
Remarkably, the program in Cincinnati has received a warm response from parents. When staff of the program attended Parent Teachers Association meetings to explain the program, there was generally a sense of relief that "finally someone was trying to do something," and virtually no opposition. The Assistant Superintendent of Curriculum Development and Support Services, Ms Kathleen Ware, remarked publicly that, of all programs she has introduced into the public school system, this is the only program "that did not receive any flak." The message seems to be that parents are extremely frustrated with the tide of teenage problems. They want to teach their children how to resist negative peer pressures, but do not have the tools to do so. This program appears to teach students to do that.
The Postponing Sexual Involement program has been tested in Atlanta; there was a significantly lower rate of reported sexual involvement and pregnancies in those who participated in the program compared with those who did not.10
Will this kind of program work in all cities? It appears that the time may be ripe for such an approach. Ten years ago, it might have been impossible to introduce such a program in public schools. But in today's world, health consciousness is "in." We teach our children about smoking, drugs, and drunk driving, and they listen. Who are those who are the most "evangelistic" against smoking? Children come home from school and "torment" their parents to stop smoking. Many of my medical colleagues have commented that the only reason they stopped smoking was not because they knew smoking was harmful to them, but because their children "harassed them to death," and they felt guilty about smoking in front of their children.
Our cultural habits have changed drastically over the last decade. In Europe, South America, and Asia, smoke-filled buses, restaurants, and convention rooms are still the norm, but not in the United States. Now we freely talk about cholesterol and exercise across the dinner table. We have become concerned about drugs and teenage pregnancy. We need not have the highest teenage pregnancy rate in the western world. We need not have the 20th infant survival rate in the world.
The habits of a new generation can be changed. We can solve this problem.
1. Stout JW, Rivara FP. School and sex education: does it work? Pediatrics. 1989;83:375379.
2. Tsang RC, Uauy R, Lucas A, Zlotkin S. Nutrient Requirements in Preterm Infants. New York, NY: Williams & Wilkins; 1993.
3. Wegeman ME. Annual summary of vital statistics- 1991. Pediatrics. 1992;90:835845.
4. Institute of Medicine, Committee to Study the Prevention of Low Birthweight. Preventing Low; Birthweigh - Summary. Washington, DC: National Academy Press; 1985:1-41. Division of Health Promotion and Disease Prevention.
5. Dobson J. Who should teach the child about sex.' In: Dare to Discipline. Wheaton. Ill: Bantam Books, Tyndale House Publishers; 1990:148-151.
6. Gordon S, Gordon J. Raising a Child Conservonveiy m a Sexually Permissive World. New York, NY: Simon & Schuster Inc; 1983.
7. Miller BC, McCoy JK, Olson TD. Dating age and stage as correlates of adolescent sexual attitudes and behavior. J Adoiesc Res. 1986;1:361-371.
8. Stout JW. The effects of sexuality education on adolescent sexual activity. Pediarr Ann. 1993;22:120-126.
9. Vincent ML, Olearie AE Schluchter MD. Reducing adolescent pregnancy through school and community-based education. JAMA. 1987;257:3382-3386.
10. Howard M, Mitchell ME. Preventing teenage pregnancy: some questions to be answered and some answers to be questioned. Pediarr Ann. 1993;22:109-118.