The Challenge in Helping Young Adults Better Manage Their Reproductive Lives

Heather D. Boonstra, Guttmacher Institute
Reproductive rights are under attack. Will you help us fight back with facts?

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In recent years, social scientists, the popular media and parents alike have become increasingly interested in the health and lives of "20- somethings." According to a range of experts, the life of a young adult today is very different from the life of a young adult just a generation ago. Today’s 20-somethings are taking longer to graduate from college, settle into a career, live independently and start a family. Indeed, researchers have suggested that there is a new and definable phase in life, spanning the decade between the late teens and late 20s, when young Americans experience their "odyssey years"—a time of wandering on the path to maturity.

Part and parcel of this new interest in 20-somethings is a focus on their sexual behavior. Much attention has been given of late to the fact that the unplanned pregnancy and abortion rates of women in their 20s are high, considerably higher than those of teenagers. This has led some to conclude that young adults are doing "worse" than teenagers in managing their sexual behavior. After years of focusing on interventions aimed at meeting the needs of teenagers, the nation has made extraordinary progress in reducing rates of teen pregnancy and childbearing. Observing this, some experts have suggested that it is now time to do the same for young adults.

It is true that young adults have many more unintended pregnancies and abortions than do teenagers, and it is certainly true that the sexual and reproductive health needs of 20-somethings merit special attention. But the picture is also a complex one. The very patterns of young adults' lives are in large part both responsible for and help explain why 20-somethings have difficulty managing their sexual lives—even as such patterns make designing and implementing interventions for individuals in this age-group especially challenging. Moreover, how poorly or well young adults fare in protecting their sexual health and managing their fertility is to a large extent dependent on the quality of the education and preparation they received when they were teens. This education appears to be lacking: Despite the undeniable progress in reducing teen pregnancy made in the final decade of the last century, the latest evidence indicates strongly that the trend line may be reversing, and that the problem is very far from "solved."

Pregnancy and Abortion in the 'Odyssey Years'

Social scientists are starting to realize a permanent shift may have taken place in the way Americans live their lives. In the past, the transition from adolescence to adulthood was very clearly marked by leaving home, finishing school, getting married and having children. Today's young adults, however, dip in and out of school, jobs and relationships, and sometimes move back in with their parents. In addition, they are delaying marriage and children: The percentage of young adults who have not married by age 25 has risen steadily since 1970 (see chart, page 14), as has the median age at first birth.

The proportion of 25-year-olds who have never been married has increased steadily since the 1970s.
Source: The Brookings Institution, 2007.

Inevitably, these demographic changes have had implications for the sexual and reproductive health of individuals and couples in their 20s, and they help explain some of the problems today's 20-somethings face. Women in their 20s are especially likely to be at risk of unintended pregnancy, because of their sexual behavior, access to and use of contraception, and desire and readiness to become pregnant. In comparison with older women, 20-somethings are more likely to be capable of having a child and, ironically, less likely—because of marital status and income—to see themselves as ready. Moreover, in comparison with teens, 20-somethings are more likely to be having sex. Finally, they are least likely to have access to contraceptive services, because of a lack of insurance coverage: Three in 10 women aged 20–24 have no insurance coverage whatsoever, the highest of any age-group (see chart). This is in part because they are less likely than teens to receive health insurance coverage through their parents and are more likely than older adults to have low-wage or temporary jobs that generally do not come with health benefits.

Women in their 20s are more likely than other women to have no health insurance coverage.
Source: U.S. Census Bureau, 2008.

Given the nature of young adults' lives, their relatively higher rates of unintended pregnancy are not so surprising. In fact, among women aged 20–24, more than one unintended pregnancy occurs for every 10 women—a rate twice that for women overall. This, in turn, leads to higher levels of abortion. Five percent of women 20–24 have an abortion each year, compared with 2% of women overall.

Women in their 20s who are not married but are living with a partner are particularly vulnerable to unintended pregnancy. About 10% of women in their 20s are cohabiting, the largest proportion of any age-group. Cohabiting women use contraceptives at rates similar to those of married women, but, because cohabiting women typically have sex more often than married women, their rate of unintended pregnancy is more than twice that of married women or of unmarried women who are not cohabiting. It may also be that cohabiting women are not as motivated as other women to use contraceptives consistently over time, perhaps because they are more ambivalent about pregnancy.

Finally, the fact remains that even many married people face considerable difficulties planning their families. Although married people have lower rates of contraceptive failure, unintended pregnancy and abortion than those who are unmarried, they still face considerable difficulties in using contraceptives consistently and correctly, avoiding unintended pregnancy and abortion, and planning and spacing their births (see box).

Marriage Is No Panacea

Just as being an adult is not in and of itself protective against problems with planning pregnancies, being married offers no sure immunity either. In fact, married people experience considerable difficulty in planning and spacing their births, and in avoiding unintended pregnancy and abortion. According to the most recent data available (2001), of the 3.5 million pregnancies among married women in this country each year, more than one-quarter are unplanned. Although most married women experiencing an unintended pregnancy carry their pregnancies to term, 27% of unintended pregnancies that occur to married women end in abortion.

Having children too early in a marriage or spaced too closely together, or raising a child that was not planned for, can place a great deal of stress on a couple's relationship. There can also be significant financial costs associated with an unplanned pregnancy. (An abortion can cost several hundred dollars, and raising a child, of course, can cost hundreds of thousands of dollars.) And although it is no secret that financial pressures can undermine relationships, there is a dearth of research about the extent to which unintended pregnancy and its consequences undermine marital stability and possibly lead to separation or divorce.

One thing is clear, however: Married people in their 20s, like unmarried people, need accurate information about their risk of pregnancy when contraceptives are not used and the importance of consistent and correct use of methods to avoid unintended pregnancy. Couples need to be encouraged to discuss issues such as methods of pregnancy prevention and decision making about childbearing. Given the large numbers of married couples who experience an unintended pregnancy and either an abortion or an unintended birth, policies and programs should ensure that married couples and couples contemplating marriage have the counseling and education they need to help them avoid these stressful events.

Promising Approaches

Over the years, many organizations and government programs have worked to help women in their 20s and their partners better manage their reproductive lives. For example, millions of women in their 20s rely on family planning centers supported largely by Medicaid and the federal Title X program for contraceptive counseling and services. In fact, women aged 20–29 comprise half of all Title X family planning center clients.

Prominent among organizations now focusing on the needs of young adults is the National Campaign to Prevent Teen and Unplanned Pregnancy. The National Campaign was established in 1996—a time of considerable public concern about adolescent pregnancy and childbearing—to work exclusively on decreasing teen pregnancy in America. Teen pregnancy declined markedly during the campaign's first decade; indeed, teen pregnancy rates had been falling steadily since their peak in 1990. Noting both the country's success in reducing teen pregnancy and the fact that there had been no similar progress in reducing unplanned pregnancies among young adults, the National Campaign decided in 2007 to expand its mission to focus on 20-somethings. "Our hope is to build on the important work already happening in this area and raise awareness that unplanned pregnancy is not just a teen problem," says Andrea Kane, the National Campaign's senior director of policy and partnerships. "If it works, our effort would reach young women and men in creative ways, help them think more seriously about pregnancy planning and prevention, and also link them to already existing sources of information and services."

Since expanding its mission two years ago, the National Campaign has largely been laying the groundwork for its new effort by generating data collection on young adults and scoping out promising opportunities. Only recently has it begun actual programming in two areas it considers especially promising: work with community colleges and work in the digital media. In late 2008, the National Campaign announced a new program area focused on students enrolled in community colleges, and awarded grants to three community colleges to test various approaches. For Mary Ellen Duncan, president emeritus of Howard Community College in Maryland and an advisor to the National Campaign, the focus on community colleges is especially compelling. "As a long-time college president, it has become clear to me that whether the opportunity for education is lost or delayed, unplanned pregnancy often makes life harder for those trying to achieve a college education."

According to the National Campaign, "first-year experience" programs and student orientation courses could be ideal places to address relationships, unplanned pregnancy and childbearing within a broader framework of goal-setting, aspirations and decision making. Community colleges could also expand peer education programs to focus on sexual health and relationships, and develop or adapt Web-based resources to provide information and answer students' questions about pregnancy prevention. Finally, although most community colleges do not have the resources to provide comprehensive health services, about half have a health center; these centers could improve the scope and quality of their services in the area of sexual health by expanding their offerings or collaborating with community groups to provide family planning education and services. Indeed, a great deal of work has recently gone into making contraceptives more affordable to college students through campus health centers (see box).

The Fight for Affordable Birth Control on College Campuses

Because of a provision in the Deficit Reduction Act of 2005, college students have been paying dramatically more since then for contraceptives. For almost 20 years, college health centers could buy prescription drugs, including contraceptives, at deep discounts. Known as "nominal pricing," this arrangement allowed pharmaceutical companies to sell their products to certain charitable groups, including university health centers and some family planning centers, at very low ("nominal") prices, without having to offer the same discounts to states' Medicaid programs. University health centers then passed along the savings to students.

All was well until accusations arose that some drug companies were abusing the exemption. In 2005, Congress narrowed the definition of those who could qualify and, in the process, precluded legitimate charitable sales to university health centers and family planning centers that are not part of the Title X program. (Family planning centers supported by Title X were not directly affected by this change and were still able to receive nominal prices.) As stockpiles of discounted drugs ran out, payments shot up: Students saw the price of oral contraceptives rise from $5 to $10 per month to $30 to $50, and some campus pharmacies have stopped stocking contraceptives altogether, making students have to go to outside pharmacies and pay out-of-pocket or with private insurance.

In 2007, Planned Parenthood Federation of America began a nationwide grassroots campaign to restore the exemption for the university health centers and family planning centers that had lost it in 2005. These efforts paid off earlier this year when Congress passed legislation to make birth control affordable again. The provision, included in the 2009 omnibus appropriations bill, restores the exemption and eliminates one major disincentive to offering steep discounts to university health centers. But other disincentives for manufacturers remain, and whether or not this change will lead them to actually lower prices on college campuses remains to be seen.

The other program area the National Campaign will soon be launching uses digital media to reach young people through blogs, downloads and social-networking Web sites, such as MySpace, Twitter and Facebook. The National Campaign is planning two new initiatives under its digital media program. The first of these, called "Sex Really," will start with an audio series on the Web featuring people in their 20s talking about their relationships and sexual health. "People in their 20s, especially women, like to talk about their relationships," says Kane. "The idea is to start a conversation about relationships, and in that context get them talking about fertility decisions and the consequences of unintended pregnancy. We found that talking about pregnancy prevention and family planning in isolation is not so exciting to young people."

The second initiative under the campaign's digital media effort will focus specifically on helping young people use contraceptives better. This effort will tap into social-networking technologies, including Web sites and mobile phones, as a way of answering young people's questions and concerns with medically accurate information about family planning. In addition, the initiative aims to link young people with providers and health clinics in their area. "If we are going to successfully reach the 20-somethings, we have to meet them where they are—and many are Internet-savvy and have cell phones," says Larry Swiader, director of digital media at the National Campaign. "We know that people in their 20s are looking for information about safer sex, pregnancy planning and HIV, but many are slow to admit how little they know. We want to find a way to satisfy that curiosity, increase their knowledge and help them change their behavior with information that is reliable and trustworthy."

Two other program areas the National Campaign has identified as promising, but is not itself working in, are the workplace and the military. In theory, the workplace would appear to have great potential, but reaching young adults there is challenging—and not only because people in their 20s are particularly mobile, and hop from job to job. Many employers, especially larger ones, participate in or sponsor worksite health promotion campaigns—which often include information on drug and alcohol use, stress management and management of chronic conditions. But many employers also may not feel that it is appropriate for them to address sexual and reproductive health issues in the workplace. Accordingly, notes Helen Darling, president of the National Business Group on Health, pregnancy prevention and planning is generally not singled out as a major initiative.

Recognizing, however, that employers could be doing more to improve the health of children, adolescents and pregnant women, Darling's organization recently released a guide that makes the case for investing in maternal and child health, including comprehensive contraceptive coverage for employees and dependents. "The health of women and children is important to employers," says Darling. "And pregnancy is the leading cause of short- and long-term disability and turnover for most companies. For employers, investing in maternal and child health is smart and good for the bottom line."

In contrast to the civilian workforce, the U.S. military is actively involved in helping enlisted young adults manage their reproductive lives, although it too faces considerable challenges. Because the military has to ensure that active duty personnel are healthy and fit for duty, it has a long history of educating military personnel about their sexual health and providing them and their families with near-universal health care. In the Navy and Marine Corps, for instance, new recruits receive a comprehensive medical examination upon arriving at boot camp, including contraceptive counseling and a pelvic exam for women and HIV testing and sexual health education for men and women. In addition, all personnel receive information annually about STI or unplanned pregnancy prevention. Condoms are accessible in numerous venues and emergency contraceptives are available in Navy pharmacies. Women have access to other contraceptive methods free of charge through a network of health care providers.

Despite the military's concerted efforts, however, unplanned pregnancy remains a significant problem. Compared with their counterparts in the general population, fewer junior enlisted women become pregnant each year, but when they do, they are somewhat more likely to report that the pregnancy was unplanned. In fact, Navy surveys consistently indicate that approximately two-thirds of pregnancies among enlisted women are unintended. Researchers have investigated the myriad issues surrounding contraceptive use among women in the Navy. One study, published in the February 2008 issue of Qualitative Health Research, found a lack of consistency in the quality of contraceptive counseling, variation in the range of contraceptive methods offered, and challenges in the work environment (particularly during deployment, when working long hours across multiple time zones) that make it difficult to use contraceptives consistently. Add to this the fact that the military is a male-dominated culture, where women are often outnumbered by men five to one, heavy alcohol use (especially while on "liberty") is not uncommon, contraception is often equated with promiscuity and male sexual prowess is highly valued.

Recognizing that more needs to be done to meet the information, education and health care needs of military personnel and their families, the Navy later this year will begin testing an intervention to increase knowledge and skills about condoms among women. "The audience we serve is young, hip, healthy, employed, sexually active, intellectually vibrant and traveling," says Bob MacDonald, manager of the Navy and Marine Corps' sexual health and responsibility program (SHARP), which will oversee the pilot project. "It's important that we provide our young adults with materials and messages that speak to them."

The Importance of Being Prepared

To be sure, helping young adults achieve greater control over their reproductive lives is critical, and policymakers, donors, public health professionals and program planners should continue to look carefully at what can be done to reach 20-somethings where they are. But even the most promising approaches are not without challenges. First, young adulthood is almost by definition a "high-risk" period, and, in some ways, there is only so much that can be done to circumscribe the flux and variety of this formative decade. Related to this is yet another challenge: Young adults are inherently hard to reach. They are less likely than older adults to be "settled down" into a career, a relationship or a home of their own, and are often disconnected from the kind of social institutions that could address their needs.

At the end of the day, moreover, how people fare in their 20s depends not only on the range and quality of interventions available to them at that time, but also on the information and skills they learned as adolescents. On this front, there is clearly more progress to be made. Teen pregnancy rates, after falling steadily since 1990, have leveled off over the last several years, and now it appears that birthrates are on the rise. The Centers for Disease Control and Prevention's National Center for Health Statistics reports a 3% national increase in teen birthrates between 2005 and 2006 (from 40.5 to 41.9 births per 1,000 females aged 15–19). This trend is reflected in data from the Youth Risk Behavior Survey that show recent-year declines in both teens' contraceptive use and their delaying of first sex. Meanwhile, research indicates that the proportion of U.S. teens who had received any formal instruction about birth control methods declined sharply between 1995 and 2002, while the proportion who received only information about abstinence more than doubled. There is clear evidence that abstinence-only programs are not effective in stopping or even delaying teen sex.

Society cannot expect young adults to magically know how to manage their reproductive lives without guidance and support. As in most other aspects of life, it is important to ensure that adolescents have the information, the personal autonomy and the interpersonal skills they will need to function as competent adults. This starts with more comprehensive sex education—programs that help young people both to withstand the pressures to have sex too soon and to have healthy, responsible and mutually protective relationships when they begin having sex, whether in their teen years or as tomorrow's 20-somethings. For her part, the National Campaign's CEO Sarah Brown understands that to truly succeed in helping young adults, we cannot abandon teens as they grapple with some of the most important personal issues they will ever face. "We need to look for creative ways to support both teens and young adults in the years ahead," says Brown. "By helping teens avoid early pregnancy, young people will have more opportunities and control over their lives, more children will grow up in intact, married families, there will be less poverty, lower public costs, a lighter burden on taxpayers and less need for abortion."