Moms Too Young

Texas Physicians Battle Teenage Pregnancy

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Public Health Feature – May 2011

Tex Med. 2011;107(5):55-61.

By Crystal Conde
Associate Editor

Teen mothers arrive at San Antonio's Seton Home scared and alone. Many of them are runaways and have been in foster care, juvenile detention, homeless shelters, or on the street. They've often escaped chaotic family situations and desperately need secure shelter and prenatal care.

These vulnerable young mothers who lack family and community support find a structured environment at Seton Home that helps them succeed in life. Kate Todd-Thompson, a third-year medical student at The University of Texas Health Science Center at San Antonio, became involved with the organization in 2009 when she started a project there to improve the residents' breastfeeding rate. In its first year, Breastfeeding Education and Support for Teens (BEST) increased the number of mothers who breastfeed and the length of time they breastfeed.

Ms. Todd-Thompson says the young mothers responded positively to the program. Participants attend meetings every other week to learn more about the health benefits of breastfeeding and what to expect once their babies are born.

Breastfeeding decreases rates of ear infections, incidences of asthma later in life, and risks of obesity in children. Ms. Todd-Thompson says mothers benefit from breastfeeding by reducing their risk of breast cancer and accelerating weight loss after pregnancy.

"BEST also enables the new moms who are breastfeeding to learn from the older moms. It's a wonderful, supportive environment," she said.

When Ms. Todd-Thompson started her demanding third-year clinical rotations in July, medical students Lara Gross and Jenny Saenz took over leadership of BEST. They continue to hold meetings every other week.

Seton Home is a licensed residential facility to help young women deliver healthy babies. It provides education to help mothers earn a high school diploma or GED, as well as parenting instruction, counseling and therapy, an onsite health clinic, and access to prenatal and postnatal care, mental health services, dental and vision care, annual exams, and emergency services. The residents' age at admission must be between 12 and 17, but the mothers can stay until they're 19. The campus has 32 efficiency apartments and eight dorm-style rooms to house 40 mothers and their children.

Alice Gong, MD, a neonatologist and member of the TMA Committee on Maternal and Perinatal Health, supervised Ms. Todd-Thompson's project. She also volunteered at the facility's clinic a few times last fall.

"I'm happy these girls have found Seton Home. They have a nurturing environment where they can have their babies and learn to care for them," Dr. Gong said.

Seton Home is one of many efforts throughout Texas aimed at connecting teen mothers with vital resources. Many physicians work in state and local programs to promote effective, proven interventions for preventing pregnancy in adolescents. In the legislature, the Texas Medical Association endorses the agenda of the San Antonio-based Healthy Futures Alliance, a community coalition to reduce teen and unplanned pregnancy.

Physicians' and medical professionals' involvement in teen pregnancy prevention efforts at any level is valuable, Ms. Todd-Thompson says.

"It's one thing to say that teen pregnancy is a problem, but it's another to dedicate your time and effort to working with pregnant teens and to see the struggles they face. To find solutions to public health problems like teen pregnancy, we have to experience it on an intimate level," she said.

TMA Supports Legislative Agenda

Texas has grappled with the cost and consequences of teen pregnancy for years.

According to the Centers for Disease Control and Prevention (CDC) National Vital Statistics Report [PDF] (vol. 59, no. 1), Texas was third in the nation in 2008 for rate of births to teenagers at 63.4 per 1,000. Mississippi was first at 65, and New Mexico was second at 64.1.

Between 1991and 2004, teenage girls in Texas gave birth to more than 745,000 babies, 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 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.  

In Texas in 2004 alone, the report says, teen pregnancy cost taxpayers an estimated $1 billion in federal, state, and local taxes, of which $552 million were federal costs and $450 million were state and local costs.

TMA member Janet Realini, MD, MPH, president of Healthy Futures of Texas, the nonprofit arm of Healthy Futures Alliance, stresses 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.

To help reduce the teen pregnancy burden, TMA supports the Healthy Futures Alliance legislative agenda. Dr. Realini says the group focused on two priorities in this year's legislative session: maximizing access to birth control and preventive care and requiring evidence-based sex education in public schools.

At press time, the organization supported several bills to renew and strengthen the Women's Health Program (WHP), which provides checkups, screenings, and birth control – not abortion – to women aged 18 to 44 whom Medicaid would cover if they become pregnant.

During a five-year demonstration project, WHP reached about 15 percent of eligible women. In just its first two years, WHP saved Texas more than $37.6 million, according to Dr. Realini. In fact, she says, Texas saved $10 for every dollar invested in the program.

She says the alliance asked the state to continue the program and to expand its reach to serve more women and save even more money. The demonstration project will end this year if lawmakers don't renew the program.

"Contraceptive access is an essential part of preventing unplanned pregnancy, whether in adults or sexually active adolescents younger than 18," Dr. Realini said.

The Healthy Futures Alliance also asked the legislature to maintain or increase funding levels for family planning programs designed to:  

  • Reduce infant mortality;
  • Provide comprehensive care for women before, during, and after pregnancy and childbirth;
  • Offer preventive and primary care services for infants, children, and adolescents;
  • Provide comprehensive care for children with special health care needs;
  • Cover infrastructure development and operating costs for family planning agencies; and
  • Provide individual and community-wide educational activities, as well as family planning clinical services.  

Due to insufficient funds, Dr. Realini says, the programs serve fewer than 20 percent of the 1.8 million Texas women in need. The alliance asked the legislature to restore $11.9 million to family planning funding and to expand the number of contractors available to serve women who need care.

"Failure to restore funding to family planning programs is penny-wise and pound-foolish. These programs help prevent unplanned pregnancy among low-income men and women, saving the state money," Dr. Realini said.

At press time, state budget constraints made passage of the alliance's agenda challenging.  

Agenda Calls for Abstinence-Plus

To improve sex education instruction in schools, the alliance also backs legislation to require public school districts to use evidencebased programs if they offer sex education. Dr. Realini says most Texas students receive ineffective and incomplete instruction about human sexuality.

According to a 2009 Texas Freedom Network Education Fund report, 41 percent of school districts use programs with inaccurate information. The report, Just Say Don't Know: Sexuality Education in Texas Public Schools, asserts that Texas schools most commonly provide inaccurate information about condoms in sex education materials. The report says most examples of inaccurate information about condoms discourage their use by exaggerating their failure rates or engaging in "condom-bashing."

The report cites the following from a student exercise used by a Central Texas school district:  

Giving a condom to a teen is just like saying, "Well, if you insist on killing yourself by jumping off the bridge, at least wear these elbow pads – they may protect you some."   

The Austin-based Texas Freedom Network says on its website that it was founded in 1995 and "is a nonpartisan, grassroots organization of more than 45,000 religious and community leaders" that "acts as the state's watchdog, monitoring far-right issues, organizations, money and leaders."

The Healthy Futures Alliance encouraged legislators to urge Gov. Rick Perry and Health and Human Services Commissioner Tom Suehs to request federal Personal Responsibility Education Program funds. The federal health system reform bill includes $55.25 million in funding for evidence-based teen pregnancy prevention. Texas can ask for its $4.4 million share of these funds to support programs in communities and schools demonstrated to affect teen behavior, according to Dr. Realini. At press time, they hadn't requested the funds.

"Ninety-four percent of Texas school districts offer abstinence-only and non-evidence-based sex education programs. The alliance doesn't want to rule out scientifically sound, evidence-based abstinence education. We want to encourage use of evidence-based programs with an abstinence-plus approach," she said.

Abstinence-plus program curricula promote abstinence as the healthiest choice for teens and use of contraception for sexually active teens.

Kimberly Carter, MD, MPP, an Austin obstetrician-gynecologist and assistant professor at The University of Texas Southwestern Medical Center's Department of Obstetrics and Gynecology, routinely cares for pregnant teenagers in her private practice.

She says giving adolescents access to birth control and equipping them with evidence-based abstinence-plus sex education curricula will help make a difference in the state's teen pregnancy rate.

"There's a myth that if we talk to teens about sex, we're giving them permission to be sexually active. That's not the case. The more accurate information about sex you give teens, the less likely they are to engage in high-risk sexual behavior. If we don't educate them accurately about sex, they're more likely to be irresponsible and to have unprotected sex," said Dr. Carter, a member of the TMA Council on Science and Public Health.

Abstinence-only programs haven't demonstrated an ability to change teens' behavior on a large scale.

A 2007 Mathematica Policy Research, Inc., report on the impact of abstinence education programs 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 hhad no bearing on likelihood of engaging in unprotected sex.

And there were no differences in pregnancies, births, and reported sexually transmitted diseases (STDs) among the two groups. The report concluded that both groups do not understand the consequences of STDs 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 [PDF], a study by Douglas Kirby, PhD, 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.

The report says 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.

Get Involved

Dr. Realini says it's important to approach teen pregnancy prevention from a community, school, and family standpoint with a scientific, evidence-based platform.

"Physicians are comfortable using scientific principles to promote healthy behaviors. When it comes to teen and unplanned pregnancy, physicians need to take those practices beyond the exam room and into the community. Physicians can help overcome misinformation and myths among parents, teachers, adolescents, and others," she said.

Physician involvement in teen pregnancy prevention matters, she says.

"It's important for physicians to be involved in community discussions about teen pregnancy. Physicians can volunteer with programs, promote evidence-based interventions, talk to their state representatives and senators, and serve on their local school district's student health advisory council [SHAC]," she said.

TMA member Manuel Ángel Oscós-Sánchez, MD, is busy as a faculty member of The University of Texas Health Science Center at San Antonio Department of Family and Community Medicine, but he's devoting time to help make a difference in local schools. He and Janna Lesser, PhD, RN, are directors of the Harlandale Independent School District Familias en Acción Community Collaborative Council for the Texas Healthy Adolescent Initiative.

The Texas Department of State Health Services (DSHS) Texas Healthy Adolescent Initiative aims to improve the overall health and well-being of Texas adolescents aged 10 to 18 by focusing on comprehensive, evidence-based youth development approaches to increase healthy behaviors and decision making among adolescents.

DSHS awarded grants to several Texas communities, including Longview, San Antonio, Dallas-Fort Worth, Austin, Houston, and Lubbock.

The health science center received a five-year grant for the initiative at the Harlandale Independent School District. The Familias en Acción Community Collaborative Council developed a fiscal year 2011­-12 strategic plan for the initiative and submitted it to DSHS in December.

The plan includes results of a community survey of 200 students and 200 of their parents and guardians. It reveals that respondents consider teen pregnancy the biggest barrier to the positive development of youth in Harlandale. Drug and alcohol abuse and violence followed closely behind on the list.

Based on the information gathered from the community survey, Familias en Acción set two primary goals for the Texas Healthy Adolescent Initiative:  

  • Increase educational success and pride, including graduating from high school, going to college, and/or attaining job and career skills; and
  • Increase families' ability to support children to achieve academic success.  

The initiative identified existing programs and events that could be modified or enhanced, while addressing multiple adolescent health issues such as teen pregnancy, violence, nutrition, exercise, and substance use. Programs and events include college fairs, teen health camps, art functions, and more.

At press time, the council was implementing interventions to augment the effects of the programs. Interventions the council has identified include a focus on preparing students for college and providing them with access to tutoring.

"The council is focused on positive youth development. When students don't have easy access to positive life options, that's when they get pregnant. We need to focus on students' aspirations and provide support so they can achieve them," Dr. Oscós-Sánchez said. 

Reaching Teen Dads

To reduce the teen pregnancy rate, it's pivotal to focus educational and preventive interventions on men, says Peggy Smith, PhD, director of the Baylor College of Medicine (BCM) Teen Health Clinics. She says young minority men often are undereducated, with a history of incarceration, and may have trouble finding a job. In some cases, they lack a positive role model and are ignorant of the basics of reproduction and child development.

"It is one of our goals to provide proactive education in these areas, as well as job training, to be sure the men we serve can succeed economically," Dr. Smith said.

The clinics encourage men to participate in family planning activities and in a Centering Pregnancy program, a collective approach to prenatal care in which expectant mothers with roughly the same due dates attend appointments together. (See "Center of Attention," October 2010 Texas Medicine, pages 45-50.) An obstetrician, nurse practitioner, or certified nurse-midwife facilitates the visit in conjunction with a registered nurse, social worker, nursing assistant, or licensed vocational nurse. Both facilitators lead discussions with mothers and fathers that address the participants' pregnancy and parenting concerns.

"By working with the partners of pregnant teens, we're addressing initial and subsequent pregnancies, as well as the enhancement of parenting skills for this group of fathers. The increasing prevalence of sexually transmitted diseases and human immunodeficiency virus [HIV] makes it imperative to focus on prevention for males and females. We also know interventions that occur early among at-risk groups are more cost-effective than those that are initiated during adulthood," Dr. Smith said.

The BCM Teen Health Clinics offer free and low-cost comprehensive primary health care, family planning services, screening and treatment for sexually transmitted infections and HIV, health risk reduction education, prenatal care, sports physicals, wellness exams, nutritional counseling, and case management.

Houston neighborhoods with high infant mortality and teen pregnancy rates are home to seven clinics.

The BCM Teen Health Clinics provide testing and immunizations, sports physicals, gynecological exams, health education, and medications for common health problems at two Houston Independent School District campuses. One campus clinic has a reproductive health program for young men and women and facilitates referrals to other community health agencies, including those for prenatal care. Baylor College of Medicine collaborates with Houston universities, the Harris County Hospital District, local and state leaders, and community organizations to help ensure Houston's young people have access to health care.

Mariam Chacko, MD, TMA member and BCM Teen Health Clinics medical director, says that last year, 98 percent of the clinics' patients were at or below 200 percent of the federal poverty level. Poverty is a contributing factor to the incidence of teen pregnancy, and she says Houston is no exception to the challenges many inner cities face.

"Risk factors for teen pregnancy can be sexual and nonsexual. They can include – but aren't limited to – living in a one-parent home, smoking, using drugs, having problems in school, or lacking a church affiliation. Sexual factors can be unprotected sexual activity, multiple sexual partners, and sexual relationships with older partners," Dr. Chacko said.

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.

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