Public Health Feature - April 2009
Tex Med . 2009;105(4):35-40.
By Crystal Conde
Nobody wins when a teenager gets pregnant. Teen mothers are more likely to drop out of school, remain unmarried, and live in poverty. Their children are more likely to be born at low birth weight, grow up poor, live in single-parent households, suffer abuse and neglect, and enter the child welfare system. Their daughters are more likely to become teen parents themselves, and their sons are more likely to end up in jail.
All these negative consequences are according to The National Campaign to Prevent Teen and Unplanned Pregnancy. San Antonio family physician Janet Realini, MD, MPH, adds another downer: The fathers of the babies are less likely to attain a higher level of education, limiting their earning potential and financial contribution to society.
Dr. Realini and other experts on the subject find a new Centers for Disease Control and Prevention (CDC) report troubling. It shows that teenage pregnancy is on the rise. Teenage births declined between 1991 and 2005, CDC says in a report issued earlier this year, but that changed in 2006 when the trend reversed for more than half of all 50 states, including Texas.
The birth rate for Texas teenagers aged 15-19 years was 78.4 per 1,000 in 1991. It dropped to 61.6 per 1,000 in 2005, but increased to 63.1 per 1,000 in 2006.
Upon closer examination of the CDC data for Texas, Brian Castrucci, director of the Texas Department of State Health Services (DSHS) Office of Program Decision Support, found that the rise in birth rates occurred among 18- to 19-year-olds, but not in those aged 15 to 17 years. He attributes the finding to higher rates of marriage among 18- to 19-year-old women and their subsequent pregnancies.
Nationally, the birth rate for teens aged 15-19 dropped from 61.8 per 1,000 in 1991 to 40.5 per 1,000 in 2005. But the rate increased to 41.9 per 1,000 in 2006.
The CDC report does show Texas improved somewhat nationally. Its National Vital Statistics Report (vol. 57, no. 7) shows Texas did drop from No. 1 in the nation for rate of births to teenagers to No. 3 in 2006, behind Mississippi (68.4 per 1,000) and New Mexico (64.1 per 1,000).
No Reason to Celebrate
Though some may applaud the state's descent from the No. 1 spot, Dr. Realini does not. Neither does Sen. Leticia Van de Putte (D-San Antonio).
"This is one list where being near the top is not good for Texas. The teen birth rate in this state is shameful. We cannot shy away from addressing this difficult topic and implementing policies to combat these disturbing statistics," Senator Van de Putte said.
Mr. Castrucci says the unique population makeup of Texas contributes to the state's high teen birth rates. Due to population changes alone, the Texas adolescent birth rate may increase 9 percent by 2020, he says.
To help reverse this pattern, Senator Van de Putte, a cadre of legislators, and the Texas Medical Association all support the legislative agenda of Healthy Futures Alliance (HFA), a community coalition working to reduce teen and unplanned pregnancy.
Dr. Realini is president of Healthy Futures, the nonprofit organization that supports HFA, and a member of the TMA Council on Public Health. Among HFA's priorities are developing comprehensive programs and policies to educate adolescents about sex and teach them effective measures to prevent unintended pregnancy and sexually transmitted diseases (STDs). Bills filed in the House and Senate would accomplish these goals and others. (See " Healthy Futures Alliance Legislation .")
In addition, TMA's Committee on Child and Adolescent Health formed the Subcommittee on Adolescent Reproductive Health to help prevent the unintended consequences of early sexual activity. The subcommittee is reviewing TMA policy on adolescent sexual health and will submit a report to the TMA House of Delegates at TexMed 2010. The report will cover adolescent sexuality and policies proven to decrease these activities and unintended consequences, as well as suggestions for proposed legislation.
TMA's adolescent sex education policy promotes age- and developmentally appropriate comprehensive, research-based programs for kindergarten through college students. The association believes effective curricula should focus on abstinence, reducing specific sexual risk-taking behaviors, reinforcing values, and providing information on responsible decision-making, social influences, and peer pressures.
TMA encourages physicians and public health professionals to promote at the state and community levels its policy advocating comprehensive sex education programs.
Carla Ortique, MD, an Austin obstetrician-gynecologist, chairs the subcommittee. She says research and data support a comprehensive approach that delays the onset of sexual activity in adolescents, and that TMA promotes a nonjudgmental, science- and evidence-based method for accomplishing that goal.
"By the time a lot of kids see us, they're already sexually active. The minute you say, 'You shouldn't be having sex,' that closes the door on communication. Part of what the subcommittee will be doing is helping physicians open up a nonjudgmental dialogue with their young patients about sex," she said. (See " What You Can Do .")
The Price of Teen Pregnancy
Although the Texas teen birth rate was down 20 percent between 1991 and 2004, teenage girls still delivered more than 745,000 babies during that period, costing taxpayers $15.1 billion, according to By the Numbers: The Public Costs of Teen Childbearing , a 2006 report of The National Campaign to Prevent Teen and Unplanned Pregnancy.Those costs were for Medicaid, welfare, foster care, and incarceration related to the consequences of teen childbearing.
When examining annual taxpayer costs associated with the children of teen mothers, the report estimates $165 million for public health care (Medicaid and State Children's Health Insurance Program), $83 million for child welfare, $161 million for incarceration, and $349 million in lost tax revenue, due to decreased earnings and spending.
The progress Texas made in reducing teen childbearing from 1991 to 2004 saved taxpayers an estimated $327 million in 2004 alone.
In Texas, the total cost to taxpayers (federal, state, and local) associated with teen childbearing was estimated to be at least $1 billion in 2004, of which $552 million were federal costs and $450 million were state and local costs. Put another way, the average annual cost in Texas was $1,276 per teen birth.
However, it's important to note that births to young teens cost more than those to older teens, and the average annual cost for a child born to a mother 17 or younger is $2,997.
Dr. Realini stresses that the $1 billion price tag of teen births is a bare minimum and doesn't take into account the many other social, indirect, and opportunity costs of teen childbearing.
Better Education Needed
Dr. Realini attributes the decreased teen birth rates in Texas from 1991 to 2005 to a combination of more adolescents delaying the onset of sexual activity and more sexually active teenagers using contraception.
In search of the reason for the recent rise in births to teenagers, Dr. Realini has formed a couple of theories, and she'll look to the Texas-specific data for answers. One trend she's noticed is that teen pregnancy almost has been glamorized, and it has received considerable attention in a number of different forums, including television and films. She says the barrage of both positive and negative messages about teen parenthood affect an adolescent audience.
The second factor she's identified involves misinformation about the effectiveness of condoms. Teenagers, parents, teachers, and nurses are reporting a pervasive misunderstanding that condoms don't work.
"I'm concerned that some of the education being delivered has focused on the limitations of condoms as birth control. That may discourage young people from using them," Dr. Realini said.
That's why part of the HFA legislative agenda requires school-based abstinence programs to disseminate scientifically accurate information about condoms and contraceptives and prohibits programs from discouraging their use by sexually active people. The legislation, known as the abstinence education bill, had not been filed at press time.
The proposed bill is part of the alliance's drive to encourage the state to adopt a more comprehensive approach to teaching sex education, which Dr. Realini refers to as "abstinence-plus" programs. These curricula encourage adolescents to delay the onset of sexual activity until they're more responsible and emotionally mature and also include positive information about birth control and condoms.
In 1996, Congress authorized $50 million annually for five years for state programs that teach abstinence-only curricula and that don't endorse or promote contraceptive use. Through the Title V Abstinence Education program, money reaches states that elect to receive the funding and provide matching dollars. Community-based abstinence education grants, totaling more than $100 million per year, flow directly to agencies around the country, many of which operate in Texas.
Dr. Realini strongly endorses abstinence as the healthiest and most effective way to prevent pregnancy and sexually transmitted infections among adolescents. However, she says while abstinence is not controversial, the abstinence-only teaching strategy is.
Strategy Change Needed
It's time for a change in how the state educates teenagers about sex, Dr. Realini believes, because abstinence-only programs haven't demonstrated an ability to change teens' behavior. Research conducted by two organizations supports her assertion.
Mathematica Policy Research, Inc. evaluated the impact of abstinence education programs. In one 2007 report, Mathematica examined four classroom-based and after-school abstinence programs in Florida, Virginia, Wisconsin, and Mississippi. Research found that adolescents in the programs were no more likely to abstain from sex than were their control group counterparts who hadn't taken part.
Additional findings indicated that program participants and the control group had similar numbers of sexual partners and had initiated sex at the same mean age. Participation in the abstinence education programs also had no bearing on likelihood of engaging in unprotected sex.
And no differences existed in the number of pregnancies, births, and reported STDs among the two groups. The report concluded that both groups do not understand STDs' consequences and that more research is necessary to reduce teen sexual activity and its negative consequences.
The National Campaign to Prevent Teen and Unplanned Pregnancy also compared abstinence programs with abstinence-plus curriculum. Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases , a study by Douglas Kirby, PhD, is available to download on the national campaign's Web site [ PDF ].
The report asserts that studies of abstinence programs haven't produced sufficient evidence to support their widespread dissemination. They haven't been shown to delay the initiation of sex, hasten the return to abstinence, or reduce an adolescent's number of sexual partners. Continued development and evaluation of abstinence programs are necessary.
In contrast, a study of 48 abstinence-plus programs showed that more than 40 percent of the programs delayed the initiation of sex, reduced the number of sexual partners, and increased the use of condoms or contraceptives. Close to 30 percent of the programs reduced the frequency of sex, and more than 60 percent reduced instances of unprotected sex.
The study also points out that none of the abstinence-plus programs hastened the initiation of sex or increased the frequency of sex, which Dr. Realini says are common but false criticisms of abstinence-plus programs.
Emerging Answers 2007 examines service-learning youth development programs for adolescents, as well. The programs involve voluntary community service projects and structured time to prepare for the projects and reflect on them. One report cited in the study found that service-learning programs delay the onset of sexual activity among middle school students, while three studies credited the programs with reducing pregnancy rates during the academic year in which the teens participated.
Dr. Realini and the HFA legislative agenda advocate a grant program in Texas to develop a curriculum to reduce teen pregnancy, modeled after Teen Outreach Program (TOP), a national afterschool program that has been operating for more than 20 years.
Evelyn Delgado, DSHS assistant commissioner for the Division of Family and Community Health Services, says youth development programs are effective. She says the ability of individual communities to tailor such programs to their adolescent population's needs will positively impact the teen birth rate in Texas.
"It's not specifically about sex but about youth development, about the future of the child and the ability of the child and the parents to emphasize future goals. That in itself is an effective way to help adolescents stay on track, be successful, and prevent unintended pregnancies," she said.
Senate Bill 591, filed by Senator Van de Putte, would create and fund a competitive grant pilot program to serve up to 75 high-risk youths in Bexar County. Dr. Realini says the price tag for such a program is about $100,000.
Currently, Healthy Futures disseminates Big Decisions, abstinence-plus sex education developed by Dr. Realini that presents medically accurate, up-to-date information to students in grades 7 through 12. The program is inexpensive to implement, consists of 10 active-learning lessons, and is free to download at www.bigdecisions.org.
Big Decisions' key messages teach teens that having sex is a big decision, that abstinence is the healthiest choice, and that teens who choose to have sex must use condoms correctly every time and get tested for STDs.
In studying the effectiveness of the program, Dr. Realini says it appears to have a positive impact on attitudes and intentions regarding abstinence, as well as improve attitudes and knowledge about contraception.
San Antonio School District, Northeast Independent School District in San Antonio, Hays Consolidated School District, Brackettville Independent School District, Edcouch-Elsa High School, and many community agencies in Texas use Big Decisions. Dr. Realini is optimistic about the promising results of the program but acknowledges that it can't be deemed science-based until a control trial is completed with teens who haven't participated in the curriculum.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
Healthy Futures Alliance Legislation
The Healthy Futures Alliance (HFA) legislative agenda, which TMA endorses, promotes programs and policies to reverse the state's increasing teenage birth rate.
The following bills in the legislative package had been filed at press time:
- Senate Bill 591 by Sen. Leticia Van de Putte (D-San Antonio) would create an evidence-based youth development competitive pilot grant program to serve as many as 75 high-risk youths in Bexar County.
- SB 592 by Senator Van de Putte and House Bill 891 by Rep. Mike Villarreal (D-San Antonio) would allow mothers at least 16 years old to consent for contraceptives.
- SB 593 by Senator Van de Putte and HB 893 by Representative Villarreal would require the Children's Health Insurance Program to cover contraceptive care (not abortion or emergency contraception) for enrolled adolescents who are at least 16 and have at least one child.
- SB 594 by Senator Van de Putte and HB 892 by Representative Villarreal would require the Texas Health and Human Services Commission to increase marketing and outreach for the Women's Health Program (WHP) and to provide targeted outreach to women after a Medicaid delivery. The Texas WHP is a Medicaid demonstration waiver project that provides limited services, such as checkups, preventive care, and birth control, but not abortion, to uninsured women aged 18 to 44 at or below 185 percent of the federal poverty level.
- SB 1076 by Senator Van de Putte and HB 1567 by Representative Villarreal, known as the abstinence education bill, requires scientific accuracy in school abstinence programs and prohibit programs from discouraging the use of condoms and contraceptives by sexually active people.
HFA also supports the following bills:
- SB 515 by Sen. Rodney Ellis (D-Houston) and HB 741 by Rep. Joaquin Castro (D-San Antonio) would require school sex education to be medically accurate and to cover the health benefits, effectiveness, and safety of contraceptive methods.
- The prevention works bill would require more outreach for WHP, school sex education to be medically accurate, and the instruction of use- and theoretical failure rates for contraceptive methods. It also would require school districts to inform parents about the content of sex education programs.
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What You Can Do
Physicians who treat adolescents shouldn't miss opportunities to educate and counsel their young patients and their parents about sex.
That's the advice from Carla Ortique, MD, an obstetrician-gynecologist and chair of the TMA Subcommittee on Adolescent Reproductive Health, and Janet Realini, MD, a family physician, president of Healthy Futures, and a member of TMA's Council on Public Health.
"Probably the most important thing TMA-member physicians can do after educating themselves on the problem of teen pregnancy is talk to their patients," Dr. Ortique said. "Obstetrician-gynecologists see the teens generally after they have already begun to engage in sexual activity. Primary care physicians have access to the adolescents and their parents before, so they have a greater opportunity to make an impact early on."
Dr. Realini encourages physicians to speak up about increased teen births and volunteer to serve on school health advisory councils (SHACs) and advise members of the councils of the science behind abstinence-plus education. To find out whether your local school district has a SHAC and to access information regarding how they're set up, visit the Texas Department of State Health Services (DSHS) Web site .
In their practices, Dr. Realini says, physicians can learn the techniques to communicate well with teens and their parents and to encourage the adolescent's ability to gain autonomy and make decisions. She recommends that doctors set aside time to talk with teenagers alone and reassure them that, unless they indicate they will hurt themselves or others, their concerns will remain confidential.
"A nonjudgmental approach and a focus on adolescents' strengths will allow physicians to communicate well with their adolescent patients," she said.
The American Medical Association has guidelines for adolescent preventive services physicians can consult for direction.
The AMA's publication Healthy Youth 2010: Supporting the 21 Critical Adolescent Objectives [ PDF ] guides physicians in improving the health of adolescents through clinical practice and community activities. The resource includes, among the 2010 objectives, goals to reduce pregnancies among adolescent females and to increase the proportion of adolescents who abstain from sexual intercourse or use condoms if sexually active.
The AMA guide encourages physicians to share the information with colleagues at medical meetings, to create a platform for educating community members about adolescent risk behaviors, to work with state medical societies in achieving some or all of the 21 objectives, and to obtain support for effective programs.
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