Contact Name
Barbara Dietsch
562-985-9488

Contact Email
bdietsc@WestEd.org

by Lorraine V. Klerman, Dr. P.H., Professor

According to a recent report from the National Center for Health Statistics, the rate of births to teenagers is declining and the decrease has been particularly marked for second births (from 221 per 1,000 15 to 19-year-olds in 1991 to 174 per 1,000 in 1996). Nevertheless, second pregnancies among teenagers remain a problem. For example, health problems for mother and infant are more likely in a second, closely spaced pregnancy. Moreover, several longitudinal studies have shown that while it is possible for a teenage mother to overcome the education and economic problems associated with one teenage birth, unless she controls her fertility, i.e., spaces her children and does not have more than one additional one, her chances of completing high school or attaining economic self-sufficiency through work and/or marriage are severely reduced.

Problems in Evaluating Programs

Because of the importance of delaying a second pregnancy to the teenage mother's health, education, and economic well-being, many programs for pregnant and parenting teenagers have tried to increase the period of time between the first and second pregnancies. But it is difficult to judge the success of these programs or to compare them because of inadequacies in study design. In order to determine program success it is necessary to follow all, or a very high percentage of women who have participated in the program for at least two years after their initial delivery, and preferably for three years. Many programs lose contact with some of their clients soon after delivery and conclusions based on only those with whom the program has retained contact are likely to be biased. Also, programs often provide aggregate data on all clients who have been in the program over a certain number of years, without controlling for the number of months that each client has been at risk for another pregnancy. Pregnant teenagers who enter a program in the beginning of the program's first year would, at the end of the program's third year, have been at risk for another pregnancy for 31 months (36 months overall minus 5 months of pregnancy); but those who entered at the beginning of the program's third year would have been at risk for only 7 months. Combining these two groups would probably result in too positive an evaluation of the program's success.

Programs should describe 6, 12, 18, 24, 30, and 36 month success rates, using as denominators only those clients who had passed those time periods and who had been followed for that entire time and thus whose fertility history was known. The numerator for the rate should be only those in the denominator who had not yet had another child. If the numbers allowed (and they seldom do in most programs), examining these rates by factors that influence pregnancy spacing, such as marital status and age, can provide insights into why a program was or was not successful. Programs can also be evaluated using the number of months between births or using a survival curve, which shows at what times the mothers begin having subsequent births.

Intervention Trials

Several randomized, controlled trials have used sophisticated techniques to determine the success of their efforts to delay subsequent pregnancies. New Chance was a 16 site demonstration program operated between 1989 and 1992. It enrolled women 16 to 22 years old who had first given birth at age 19 or younger, were receiving AFDC, and did not have a high school diploma or GED certificate. New Chance offered comprehensive services with an emphasis on employment preparation and on personal and child development. Instruction in family planning was included. The Manpower Demonstration Research Corporation, which conducted the study, reported that twelve months after entry into the program 11% of these mothers had given birth again, the same percentage as in the control group. At 24 months after program entry, the percentages were 35 and 34; and at 36 months, 49% and 50%. The program had not succeeded in postponing subsequent, mostly second, births.

The Teenage Parent Demonstration was a three site project operated between 1987 and 1991. It enrolled first-time teenage parents who were newly eligible for welfare or who were part of a welfare case when they gave birth. Services offered included case management and workshops designed to promote personal and parenting skills, increase awareness of contraceptive measures and STDs, and prepare for later education, training, and employment. Mothers were required to participate in the program or be subject to substantial reductions in welfare benefits. Mathematica Policy Research, which evaluated the program, reported that approximately two and a half years after enrollment 50% of the women in the Camden site, 43% of those in the Newark site, and 60% of those in the Chicago site had given birth again, as compared to 52%, 38%, and 56% in the control groups at the respective sites.

The Colorado Adolescent Maternity Program used a combination of educationally-oriented focus groups and financial incentives to try to delay subsequent pregnancies, but had no positive impact.

The nurse home visitation program, operated in Elmira from 1978 to 1983 and in Memphis from 1988 to 1992, showed reductions in subsequent pregnancies. These projects enrolled pregnant women with no previous live birth and at least one risk factor. Nurses specifically trained for these projects visited the women frequently during pregnancy and, for some, until the child's second birthday. Data have not been published for teenagers only, but in the Memphis sample (mean age = 18; 18 years of age or younger - 64%) only 22% of those visited during pregnancy and for two years postpartum had another live birth by two years postpartum as compared to 31% of those who were not visited.

Conclusions

More research is needed to determine why such a large proportion of teenagers have their second child so soon after the first. A better understanding of this phenomenon would enable program developers to design more effective programs. (For a more complete overview of this subject, read: Greer, F.M., Levin-Epstein, J., One Out of Every Five. Teen Mothers and Subsequent Childbearing. Washington, DC, Center for Law and Social Policy, 1998.)

Department of Maternal and Child Health, School of Public Health, University of Alabama at Birmingham Preparation of this article was made possible, in part, by a grant from the Maternal and Child Health Bureau (MCJ 9040).