Advancing Sexual and Reproductive Health and Rights
 
The Guttmacher Report on Public Policy
February 2002, Volume 5, Number 1
 
Special Analysis

Teen Pregnancy: Trends And Lessons Learned

During the 1990s, teenage pregnancy rates and birthrates declined to record low levels. Even with this progress, however, the U.S. teen birthrate is one of the highest in the developed world. Research on what is behind the U.S. declines and why rates nonetheless are lower in other countries may help in crafting responses to the problem.
By Heather Boonstra

Many of the provisions of the 1996 law overhauling the nation's welfare system will expire at the end of the current fiscal year on September 30. The reauthorization process likely will set the stage for a major debate over one of the law's main stated goals, reducing out-of-wedlock births, and how best to achieve it. Social conservatives favor programs and policies encouraging marriage and promoting abstinence from sexual intercourse outside of marriage for people of all ages. Others suggest that it would be more appropriate and more effective for policymakers to concentrate on finding ways to sustain recent declines in teenage pregnancy and childbearing, since half of first nonmarital births are to teens and almost eight in 10 teen pregnancies are unintended.

The declines in recent years in teen pregnancy rates and birthrates are impressive: Both now stand at record low levels. However, the United States still lags far behind other developed countries, whose rates have fallen to much lower levels. New research suggests that going forward, more realistic views of young people's sexuality and their needs as they make the transition to adulthood, along with more-comprehensive approaches to meeting those needs, may be in order.

Key Trends Over Time

Childbearing. The rate of teen childbearing in the United States has fallen steeply since the late 1950s, from an all time high of 96 births per 1,000 women aged 15-19 in 1957 to an all time low of 49 in 2000 (see chart below). Birthrates fell steadily throughout the 1960s and 1970s; they were fairly steady in the early 1980s and then rose sharply between 1988 and 1991 before declining throughout the 1990s. In recent years, this downward trend has occurred among teens of all ages and races.

Divergent Trends
Since the 1950s, the U.S. teen birthrate has declined while the proprotion of teen births that are nonmarital has increased.

Note: Data for 2000 are preliminary. Source: National Center for Health Statistics, "Births to Teenagers in the United States, 1940-2000," National Vital Statistics Report, 2001, Vol. 49, No. 10.

Unmarried childbearing. Even though teen childbearing overall has declined steeply over the last half-century, the proportion of all teen births that are nonmarital has increased equally dramatically, from 13% in 1950 to 79% in 2000 (see chart). Two factors are at play. The first is that marriage in the teen years, which was not uncommon in the 1950s, has by now become quite rare. (By the mid-1990s, the typical age of first marriage in the United States had risen to just over 25 for women and 27 for men.) The second is that this trend has extended to pregnant teens as well: In contrast to the days of the "shotgun marriage," very few teens who become pregnant nowadays marry before their baby is born.

Abortion. Birthrates rise and fall as a result of changes in the rate at which women become pregnant or resolve their pregnancies in abortion, or a combination of both. Among teens in the United States, at least in recent years, declining birthrates are not the result of more pregnant teens opting to have an abortion. The U.S. teen abortion rate, after rising through the 1970s and holding fairly constant during the 1980s, then began a steady decline. By 1997, the rate was 28 abortions per 1,000 women 15-19—33% lower than the rate a decade earlier.

Pregnancy. Recent declines in teen birthrates, then, are attributable to reductions in pregnancy rates. In the 1970s and early 1980s, the U.S. teen pregnancy rates rose. They remained steady through the 1980s, even as sexual activity among teens increased, due to improved contraceptive use among those teenagers who are sexually active. The rates declined 19% from 117 pregnancies per 1,000 women aged 15-19 in 1990 to 93 per 1,000 in 1997—the lowest rate in 20 years. The recent decline is particularly encouraging, because—as with the teen birthrate decline—all population groups followed a similar pattern, regardless of young women's age, marital status, race or ethnicity.

Why the Rates Are Down

If recent declines in teen childbearing are the result of fewer teens getting pregnant in the first place, the obvious next question is: why? Are fewer teens avoiding pregnancy by abstaining from sex, or are those who are having sex using contraception more successfully?

Not surprisingly, the answer is: both. But deconstructing that answer is critical, because it goes to the heart of a number of relevant and timely public policy questions, among them the debate over public funding for abstinence-only education and for more-comprehensive approaches (see related story,).

In 1999, researchers at The Alan Guttmacher Institute (AGI) analyzed the reasons behind the recent declines in the U.S. teen pregnancy rate, using data from two comparable, large-scale government surveys, the 1988 and 1995 cycles of the National Surveys of Family Growth, and recent information on rates of teenage pregnancies, births and abortions. AGI's methodology follows the consensus of a group that was convened by the National Institute of Child Health and Human Development to examine measurement issues regarding teen sexual activity and contraceptive use, which included researchers from AGI, the National Center for Health Statistics, The Urban Institute, Child Trends and the National Campaign to Prevent Teenage Pregnancy.

The AGI analysis concluded that approximately one-quarter of the decline in teenage pregnancy in the United States between 1988 and 1995 was due to increased abstinence. (The proportion of all teenagers who had ever had sex decreased slightly, but nonsignificantly, during this period, from 53% to 51%.) Approximately three-quarters of the drop resulted from changes in the behavior of sexually experienced teens. (The pregnancy rate among this group had fallen 7%, from 211 per 1,000 to 197.)

The researchers considered a number of behavioral changes that could explain why a smaller proportion of sexually experienced teenage women became pregnant in 1995 than in 1988, including the possibility that they were having less sex. However, they found that, overall, there was little change between the two years in how often sexually experienced teenagers had intercourse.

Instead, the researchers found that overall contraceptive use increased—but only slightly, from 78% in 1988 to 80% in 1995. More importantly, teenagers in 1995 were choosing more-effective methods. A significant proportion had switched to long-acting hormonal methods that were introduced to the U.S. market in the early 1990s, namely, the injectable contraceptive (Depo-Provera) and the contraceptive implant (Norplant). By 1995, more than one in eight teen contraceptive users (13%) was using a long-acting method, and primarily because of this shift, sexually active teens became increasingly successful at avoiding pregnancy.

U.S. Still Lags

Despite all this good news, the fact remains that teenagers in the United States continue to experience substantially higher pregnancy rates and birthrates than do teens in other Western industrialized countries (see chart). The adolescent pregnancy rate in the United States, for example, is nearly twice that in Canada and Great Britain and approximately four times that in France and Sweden. Moreover, teen birthrates have declined less steeply in the United States than in other developed countries over the last three decades.

Unfavorable Comparison
Teenage birthrates declined less steeply in the United States than in other developed countries between 1970 and 2000.

*Data are for 1997 in Canada, 1998 in France and 1999 in England, Wales and Sweden. Source: Darroch JE et al., Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Occasional Report, New York: AGI, 2001, No. 3, page 14.

In order to learn more, AGI initiated a large-scale investigation in collaboration with research teams in Canada, France, Great Britain and Sweden. Between 1998 and 2001, each team prepared a case-study report for their country, including quantitative data on sexual and reproductive behavior, information documenting social attitudes and service delivery, and examples of relevant policy and program interventions. AGI synthesized key findings in a report, Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made?, published in November 2001.

The research explored the roles of several key factors expected to contribute to variation among countries, including two commonly given explanations for why rates are so much higher in the United States: that U.S. teenagers are more sexually active and that the United States has a higher proportion of its residents living in conditions of poverty and social disadvantage.

In fact, the study found that levels of sexual activity and the age at which teenagers initiate sex do not vary appreciably across the countries and are simply too small to account for the wide variations in teen pregnancy rates. Rather, teen pregnancy and childbearing levels are higher in the United States, they found, largely because of differences in contraceptive use. Sexually active teens in the United States are less likely to use any contraceptive method and especially less likely to use highly effective hormonal methods, primarily the pill, than their peers in other countries (see chart). U.S. teens who become pregnant are also less likely to opt to have an abortion, whether due to lack of abortion access, higher levels of antiabortion sentiment or greater acceptance of teen motherhood.

Teens and Contraception
U.S. teens are less likely to use a contraceptive method, and to use a hormonal method, than teens in other developed countries.

*Data are for 18-19-year-olds. †The condom category includes all methods other than the pill, but the condom is the predominant "other method." ††Data are for 16-19-year-olds. Note: Users reporting more than one method were classified by the most effective method. Data are for early to mid-1990s. Source: Darroch JE et al., Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Occasional Report, New York: AGI, 2001, No. 3, page 33.

The study did find, however, that across all of the focus countries, young people growing up in disadvantaged economic, familial and social circumstances are more likely than their better-off peers to engage in risky behavior and have a child during adolescence. It is true, therefore, that pregnancy and birth are more common among U.S. teens in part because the United States has a greater proportion of disadvantaged families. (While the United States has the highest per capita income of the study countries, it also has the highest percentage of its population who are poor.) However, at all socioeconomic levels, American teenagers are less likely than their peers in the other study countries to use contraceptives and more likely to have a child. For example, U.S. teenagers in the highest income subgroup have birthrates that are 14% higher than similar teenagers in Great Britain and rates that are higher than the overall teen birthrates in Sweden and France.

Lessons Learned

The AGI study also provides valuable insights into the reasons pregnancy and birth among teenagers are so much less common in other developed countries.

Childbearing regarded as adult behavior. There is a strong consensus in the European study countries as well as Canada that childbearing belongs in adulthood, generally considered to be when young people have completed their education, have become employed and independent from their parents and are living in stable relationships. The study concludes that in the United States, this attitude is much less strong and much more variable across groups and areas of the country.

Clear messages about sexual behavior. While adults in the other countries strongly encourage teens to wait until they have established themselves before having children, they are generally more accepting than American adults of teens having sex. In France and Sweden in particular, teen sexual expression is seen as normal and positive, but there is also widespread expectation that sexual intercourse will take place within committed relationships. (In fact, relationships among U.S. teens tend to be more sporadic and of shorter duration.) Equally strong is the expectation that young people who are having sex will take actions to protect themselves and their partners from pregnancy and sexually transmitted diseases. In keeping with this view, state or public schools in England and Wales, France and Sweden and in most of Canada teach sexuality education and provide comprehensive information about prevention. In addition, the media is used more frequently in government-sponsored campaigns for promoting responsible sexual behavior ("Promoting Contraceptive Use and Choice: France's Approach to Teen Pregnancy and Abortion," TGR, June 2000).

For adults in the United States, on the other hand, the fact that young people are having sex is more often considered to be, per se, the "problem." Because teens are often regarded and portrayed as being incapable of using contraception effectively, having sex is often equated with becoming pregnant and a teen parent; the slogan of one state's current teen pregnancy campaign is "You play, you pay." Moreover, the United States is the only country with formal policies directing state and federal funds toward educational programs that have as their sole purpose the promotion of abstinence. Over one-third (35%) of all local U.S. school districts that have policies on sexuality education require that abstinence be taught as the only appropriate option for unmarried people and that contraception either be presented as ineffective in preventing pregnancy or not be covered at all. Among school districts in the South—where birthrates are significantly higher than the national average—that proportion is 55%.

Access to family planning services. In countries that are more accepting of teenage sexual relationships, teenagers also have easier access to reproductive health services. In Canada, France, Great Britain and Sweden, contraceptive services are integrated into other types of primary care and are available free or at low cost for all teenagers. Generally, teens know where to obtain information and services and receive confidential and nonjudgmental care, the study reports.

In the United States, where attitudes about teenage sexual relationships are more conflicted, teens have a harder time obtaining contraceptive services. Many do not have health insurance or cannot get birth control as part of their basic health care. A high proportion turn to family planning clinics, where the cost of contraception is less and where, under current federal law, confidentiality is guaranteed. (There have been numerous attempts over many years to reverse this policy.) And even the guarantee of confidentiality may be a double-edged sword. It protects teens (research has shown that confidentiality is essential to many teens' willingness to come in for services), but because it is not necessarily the norm in more "mainstream," private-sector care, it may also reinforce the notion that by seeking services, teens are doing something "wrong."

Youth Development. The study found that the other study countries are all committed, although to varying degrees, to the idea of the "welfare state," and several provide considerable assistance to young people across-the-board to ease the transition from adolescence to adulthood. France, Sweden and to some extent Great Britain and Canada seek to help all teens with vocational training and education and help in finding work and unemployment benefits. These supports, say researchers, increase teenagers' ability to plan for the future—and their motivation to delay pregnancy and childbearing.

The U.S. approach, on the other hand, emphasizes individual responsibility for one's own welfare. Education, training and employment are generally up to teens themselves, with the help of their families. In keeping with this tradition, government assistance for teens in the United States is targeted primarily to those who have already dropped out of school or otherwise "slipped through the cracks." These programs may be critical to the well-being and outlook for the future of small numbers of highly vulnerable teens, but they are unlikely to play much of a role, if any, in the reproductive behavior and decisions of U.S. teens generally.

Policy Implications

When reauthorization of the 1996 welfare law begins in earnest this year, as well as during the annual appropriations process, there will be loud debate over proposals, enthusiastically backed by the Bush administration, to launch new marriage promotion initiatives and to expand abstinence-only education programming. Many scholars as well as advocates, however, are uneasy with the notion of government as "marriage broker." And they question whether government effectively can—or even should—spend its capital on morality-based campaigns to convince people who are unmarried not to have sex. The research presented here, in fact, indicates that this approach is driven more by ideology than evidence. It strongly suggests that more-realistic attitudes about young people's sexuality and more-comprehensive responses to their needs, broadly defined, as they make the transition from adolescence to adulthood would be the more-appropriate approach.

Rep. Benjamin L. Cardin (D-MD) is one member of Congress who understands this. Cardin is ranking minority member of the Human Resources Subcommittee of the House Ways and Means Committee, which will play a key role in the welfare reauthorization process. At a November 2001 hearing on teenage pregnancy, Cardin articulated what he believes the government should be doing to build on the current progress: "I would say that we should continue our focus on personal responsibility; we should do a better job of not only funding local efforts to combat teen pregnancy, but also of highlighting successful programs; we should increase access to youth development and after-school programs that give teenagers productive activities to pursue; and we should promote the value of abstinence without undercutting our commitment to providing access to and information about contraception."

This article was supported in part by the U.S. Department of Health and Human Services under grant FPR00072. The conclusions and opinions expressed in this article, however, are those of the author and AGI.