The federal government's investment in attempting to dissuade young people from initiating sexual activity through "abstinence-only" education has skyrocketed over the past few years. By definition, these efforts are focused on helping teens prevent a first pregnancy. Meanwhile, investment in "secondary prevention"—providing services to pregnant and parenting teenagers and helping them to avoid a subsequent pregnancy—remains minimal, despite the fact that second and higher-order teenage births are a significant problem in this country.

New research shedding light on the factors responsible for recent declines in the rate of second births to teens and pointing toward program models that appear to work to help teenage parents avoid a second pregnancy may call for a reappraisal of current priorities. Already, one key House member has quietly initiated an effort to reinvigorate existing federal secondary prevention policy.

Scope of the Problem

Repeat births represent more than one in five births to teenagers, or approximately 110,000 births in 1998. These births are often closely spaced: Almost one in three women whose first birth occurred before age 17 has a second birth within 24 months. The large majority of repeat births to teenagers—seven in 10—occur to those who are unmarried. Significantly, most of these young mothers say they did not want to become pregnant again so soon.

These repeat births come at a great cost to the teenage mothers themselves, their children and society at large, because the problems associated with teenage motherhood are particularly acute for, and are less likely to be overcome by, teenagers who are parenting more than one child. Indeed, research shows that teenagers who have subsequent births—particularly closely spaced births—are less likely to obtain a high school diploma, and are more likely to live in poverty or receive welfare, than those who have only one child during adolescence. The risks of low birth weight and poor health outcome also increase for babies born to teenagers who already have a child, and these children may also be more likely to suffer from child abuse or to be placed in foster care. Finally, the public costs of caring for many of these families are significant.

Trends and Explanations

Although rates of repeat births among teenagers remain high, the good news is that they decreased significantly during the 1990s, even more so than did teenage pregnancy rates generally. Researchers at The Alan Guttmacher Institute (AGI) found that between its peak in 1990 and 1996, the overall U.S. teen pregnancy rate declined by a striking 17%. Similarly, data from the National Center for Health Statistics (NCHS) show that the 1998 teenage birthrate had fallen 18% from its peak in 1991 to a level that approached an all-time low. While the rate of first births to teenagers declined by 13% during that time, the rate of second births to teenagers fell by a full 21%.

New research helps explain recent declines in teen pregnancy overall and, more specifically, the impressive decline in repeat births among teenagers. An AGI analysis of data from the 1988 and 1995 cycles of the National Survey of Family Growth indicates that while approximately one-quarter of the decline in the teenage pregnancy rate between those years is due to increased abstinence, approximately three-quarters is attributable to improved contraceptive use among sexually active teenagers. The analysis notes that teenage contraceptive users are increasingly switching from the pill to highly effective, long-lasting hormonal contraceptive methods that only recently came on the market—the contraceptive implant, Norplant, and to an even greater extent the three-month injectable, Depo-Provera. Going a step further, NCHS researchers suggest that the fact that one in four teenage mothers relies on these long-lasting methods—compared with slightly over one in eight teenagers generally—may be an important factor explaining the recent decline in their rate of second births.

Interventions That Work

To date, few programs have demonstrated scientifically their ability to reduce second births to teenagers. Yet, there is mounting evidence suggesting that one long-term, integrated, health-based approach can yield results in diverse communities. This model—a home nurse visitation program—was first studied formally in 1978 in the largely white, semirural community of Elmira, New York. Nurses visited the homes of low-income, pregnant young women (half of whom were younger than 19) for approximately two and a half years. The visits were designed to help the young women improve their health-related behaviors and parenting skills. They also emphasized life-course development, including educational achievement, participation in the workforce, and the importance of pregnancy planning. Two years after the end of the program, the nurse-visited women had experienced 43% fewer subsequent pregnancies, a 12-month increase in interbirth intervals and greater participation in the labor force compared with women participating in a control group. Their children experienced fewer emergency room visits and childhood injuries; a 15-year follow-up found that they also had reduced rates of child abuse, involvement with the criminal justice system, and high-risk behaviors such as cigarette and alcohol use and early sexual activity.

Recently, these findings were replicated among a population of low-income, black, young women (two-thirds of whom were younger than 19) living in a major urban area. A study reported in the April 19 issue of the Journal of the American Medical Association found that five years after the birth of a first child, nurse-visited women in Memphis, Tennessee, had 14% fewer subsequent pregnancies, a 34% reduction in closely spaced pregnancies and a four-month greater interbirth interval compared with women in a control group. The study also found decreased welfare dependency and increased rates of employment. While the cost of the home visits ran $2,800 a year per family, the authors suggest that healthier children and more self-sufficient mothers will offset these costs in the long run.

In a review of various care programs for teenage mothers, Rebecca Maynard, trustee professor of education and social policy at the University of Pennsylvania, highlights the fact that only those that adopt an overall health focus—and that have a strong family planning component—are successful in reducing repeat pregnancy rates. Maynard emphasizes that the effectiveness of such interventions depends on a counselor's ability to help a young mother understand the importance of waiting to become pregnant until she is better able to care for herself and her family, to help her set goals (including goals involving contraceptive use) and to help her to be committed to achieving those goals. This, she says, entails speaking in an authoritative way about contraception and providing teenage mothers with the support and guidance they need to avoid contraceptive failure (rates of which are extremely high among this subpopulation of teenagers). In the case of the Elmira model, Maynard writes, "nurses are trained to follow strict service delivery protocols and to be much more direct than welfare caseworkers in their dealings with clients. The nurse home visitors in these programs may simply have been more willing to tell clients to use birth control and to follow up to ensure they were not only using contraceptives but using them correctly."

Other experts agree on the importance of a strong family planning component. Lorraine V. Klerman, a professor in the Department of Maternal and Child Health at the School of Public Health at the University of Alabama at Birmingham, says, "the integration of family planning into an overall plan for the woman's future and the lack of separation between the teaching of family planning and the teaching of other skills seems important." Klerman further notes that in the case of the home nurse visitation program, "the same person taught it all."

Federal Policy

Title X and other federal programs that provide subsidized family planning services play a vital role in serving teenagers in need of contraception, including teenage mothers. Specific responsibility for providing care to pregnant and parenting teenagers, however, has fallen for over two decades to the Adolescent Family Life Act (AFLA) and its predecessor, the Adolescent Health Services and Pregnancy Prevention and Care Act.

Enacted during the Carter administration in 1978, the adolescent health services program was designed "to prevent unwanted early and repeat pregnancies and to help adolescents become productive, independent contributors to family and community life." Introduced by Sen. Edward M. Kennedy (D-MA) and pursued aggressively by Joseph Califano, then-secretary of the Department of Health, Education and Welfare (now the Department of Health and Human Services [DHHS]), the law funded grants to organizations that promised to bring together all the services that pregnant adolescents and adolescent parents might need in order to become "responsible parents and contributing members of society"; family planning was a required service. The law also established the Office of Adolescent Pregnancy Programs (OAPP), which remains in existence today at DHHS.

In 1981—the first year of the Reagan administration—the adolescent health services program was repealed and replaced with AFLA. Advocated by "profamily" groups and sponsored by Sens. Jeremiah Denton (R-AL) and Orrin Hatch (R-UT), the new program had as a key purpose the prevention of first pregnancies among teenagers by funding and evaluating "family-centered" programs designed to promote teen abstinence. However, at Kennedy's insistence, only one-third of the funding available for grants under the program could support abstinence-focused primary prevention projects; the remaining two-thirds of the program's grant funding would continue, along the lines of the 1978 act, to support comprehensive care services to pregnant and parenting teenagers. While AFLA care funds can be used to directly provide contraceptive services only in the most limited of circumstances, care programs are required to provide information and referrals for contraception and to make maximum use of available Title X funds.

The prevention component of AFLA was besieged by controversy from the start and, as a result, remained very much in the public eye ("Whatever Happened to the Adolescent Family Life Act?" TGR, April 1998, page 5). Nonetheless, AFLA continued as a predominately care-oriented program through 1996—the year Congress enacted a major welfare reform law that also created a massive new abstinence-only education program. The following year, Congress approved language in an annual appropriations bill waiving AFLA's statutory requirement that two-thirds of program funding support care projects. Instead, Congress directed that the bulk of AFLA funding that year go to primary prevention projects and that those projects adhere to the welfare law's stringent eight-point definition of abstinence-only education, in which even discussion of contraception beyond failure rates is prohibited ("Fueled by Campaign Promises, Drive Intensifies to Boost Abstinence-Only Education Funds," TGR, April 2000, page 1). This policy rider has been carried over on an annual basis and remains in effect today; of the $19 million in AFLA funding available in FY 2000, only a small proportion—approximately $4 million—was available for care projects.

Looking Ahead

Given the increasing state of knowledge about factors responsible for the declines in second births to teenagers and interventions that show evidence of success, at least one prominent member of the House believes it is time to reinvest in secondary pregnancy prevention. In May, Rep. Nita M. Lowey (D-NY), a senior member of the Appropriations Committee, successfully added $5 million to the pending AFLA appropriation for FY 2001 and earmarked it for the care of pregnant and parenting teens.

While it is unclear at this stage of the appropriations process whether Lowey's increase will become law, Patrick Sheeran, director of OAPP, expects there to be a great deal of interest in such an effort. Sheeran says that the field is "clamoring" for more support for programs for pregnant and parenting adolescents, with OAPP receiving many more requests for care projects than it can fund. "With the passage of welfare reform," says Sheeran, "many agencies in the field feel that pregnant and parenting adolescents are in greater need of health, education and social services than ever before. And, of course," he continues, "preventing additional pregnancies to parenting teenagers is crucial to any care program's ultimate success."