Challenging Dogma


...Using social sciences to improve the practice of public health

Wednesday, April 25, 2007

A Critique of New Chance’s Efforts to Delay Repeat Pregnancies Among Adolescent Mothers — Sara Stry

Definition and Scope of Problem: Adolescent Childbearing
In the United States, approximately 900,000 adolescent girls (15-19 years of age) become pregnant each year, or 9% of all adolescent girls in the United States (1). Although rates of adolescent childbearing have declined in recent years, the United States continues to have one of the highest adolescent pregnancy rates in the developed world (2).
Among adolescent mothers, the 2003 national rate of repeat childbirth is 20% (3). Healthy People 2010 calls for a reduction in rapid repeat births (RRB), defined as a repeat birth within two years of index birth (4). When applied to the adolescent population RRB refers to any repeat birth during adolescence.

Research shows that adolescent mothers, who continue childbearing during their adolescence, have poorer health, educational and economic outcomes than adolescent mothers that delay subsequent births (5-6). An additional birth to a young mother also brings consequences to her children and to society as a whole. The following chart illustrates current research surrounding the consequences of adolescent childbearing to the adolescent, the baby and the public.

For the adolescent:
Increased risk of low educational attainment (7)
Increased risk of chronic poverty and welfare dependence (8)
Increased risk of adverse parenting or heightened parenting stress (9)
For the baby:
Increased risk for physical abuse, abandonment or neglect (10)
Increased risk of dropping out of school (11)
Increased risk of becoming an adolescent mother themselves (12)
Increased risk of incarceration (among adult sons of teen mothers) (13)
For the public:

In 2004, teen childbearing cost US taxpayers $9.1 billion (14)
The decline in the teen birth rate between 1991 and 2004 saved taxpayers $6.7 billion in 2004 alone (15)

Near half of children born to adolescents have their medical care covered through government subsidized care (16) This research has been used to garner support for repeat pregnancy reduction programs in numerous ways. Grant proposals have cited it to ensure or request program funding and lobbyists have used it to persuade politicians to support specific public policies. Unfortunately financial and political support is not enough to solve public health problems. The structure of a program, the reality of the populations being served and the social theory behind the program must all be understood before solutions to a problem, such as adolescent repeat pregnancy begin to emerge.

New Chance Program Description
New Chance was an adolescent subsequent pregnancy prevention demonstration program that operated between 1989 and 1992 in 16 locations (within 10 states). The target population was disadvantaged adolescent mothers who had dropped out of high school. The program had three goals: 1) delay subsequent pregnancies (subsequent was defined as any additional pregnancy before the age of 20 or a pregnancy within 2 years), 2) assist young mothers with their educational and vocational goals and 3) improve health outcomes for the mother and child (17).

Upon extensive evaluation of New Chance the following outcomes were determined, New Chance’s experimental group: 1) did not have reduced pregnancy or childbearing rates when compared to the control group, 2) did not have improved educational achievement (measured by reading test scores) when compared to the control group and 3) experienced healthy status outcomes that were worse than those of the control group (e.g. clinical depression, reported stress) (18). I will argue that New Chance was unable to satisfy these program goals because the program structure did not adequately consider the special needs of adolescents, the program assumed that all teens viewed pregnancy as a negative consequence to sex and had unintentionally become pregnant, and finally the program failed to understand the repercussions of its population’s mental health needs.

Structuring Programs for Adolescents
New Chance did not adequately consider the unique needs of adolescents when developing the program. First, the structure of New Chance was too similar to the structure of a traditional school day considering that the population being served had recently dropped out of school. New Chance ran vocational and parenting classes from 9:00 am- 3:00pm five days a week, with several New Chance sites operating within a school. Attendance was expected each day. Even though the material being taught at New Chance was more applicable to the teen’s lives than traditional high school the structure of the program was much too reminiscent of their previous school experience to be engaging or effective. By putting the New Chance staff in teaching roles the teens immediately identified staff members as authoritative figures rather than supportive and caring mentors. Overall the school day structure of the program encouraged teens to view New Chance as “school” which for many of the teens may have brought on feelings of discouragement and inadequacy.

Absenteeism was cited as a major contributing factor to the disappointing results of the program (19). Reported reasons for absenteeism included: illness (mother and/or child), inadequate child care and conflicting appointments (20). Other possible reasons include: transportation issues, stress, etc. Several of these issues could have been resolved by incorporating home visits into the program. Providing services to the teen in her home eliminates the need for childcare, transportation costs and allows the home visitor and teen to connect on a more personal level.
New Chance’s program did not incorporate the adolescent’s family or baby’s father into the program. Since most adolescent mothers continue to live with their parents or a caregiver after birth it’s natural to incorporate the young mother’s parent/caregiver into the program. The amount of social support these family members provide for the adolescent may determine the long term success of the young family. It may also be important to include family/caregivers into the program whenever possible so they do not feel alienated or defensive about the outside support and services being received by the teen.

New Chance did not adequately consider the timing of their intervention. In other words, the program may have been too late to successfully change the sexual behavior of teens. The teens enrolled in the program were on average 19 years old and had their first child when they were about 17 (21). This means that “risky” sexual behaviors had very likely resumed since their first birth. The program’s results may have been different had New Chance begun giving clear contraception messages to teens while still pregnant with the first child. Establishing clear contraception messages to teens before they become involved in day to day motherhood tasks has proven to be more effective than after the birth of the baby (22).

Understanding Adolescent’s Perceptions of Pregnancy
The field of public health often views teenage pregnancy as a negative consequence of risky sexual behavior; however it’s possible that many adolescent’s hold different perceptions of pregnancy. New Chance is one of many teen pregnancy prevention programs that followed the Problem Behavior Model. This model approaches a problem (e.g. adolescent pregnancy) in the context of other deviant adolescent behaviors (e.g. poor school performance, substance abuse, etc.) (23). Although widely accepted this social behavior model does not adequately capture the reality of all adolescents. Additional consideration must be given to disadvantaged adolescents living in neighborhoods and families where academic and career achievements are undervalued (24). For these adolescents autonomy may be alternatively established through the creation of one’s own family.

The Problem Behavior Model also does not allow for the way cultural/family values influence adolescent pregnancy. For example, less effective means of contraception or close birth spacing may be a priority for specific cultures and consequently influence the rate of adolescent subsequent pregnancies.

The Theory of Reasoned Action may also be used when attempting to understand a particular adolescent’s idea of “normal” sexual behavior or “normal” age for childbearing. Clearly not all teenage pregnancies are intended; however a program, such as New Chance, must consider the possibility of intended pregnancies and identify and address prevention measures to teens appropriately (i.e. reproductive life plans, increased family involvement, peer influence).

Acknowledging a Population’s Hierarchy of Needs
Evaluations of the New Chance program demonstrate that Maslow’s Hierarchy of Needs was not adequately considered during program design. As reported earlier the experimental group experienced health status outcomes that were worse than those of the control group (e.g. clinical depression, reported stress). Upon initial entrance to New Chance the young mothers were assessed for their risk of clinical depression. Of the 2,322 women selected for the study (including both experimental and control groups) over half registered scores indicting that they were at risk for clinical depression (25). Despite the high risk for depression New Chance did not offer mental health counseling to the young mothers. According to Maslow’s Hierarchy of Needs it is therefore unrealistic to expect the adolescent mothers to have met the academic and vocational goals (i.e. esteem needs, cognitive needs) set by the program because they had not yet addressed their own mental health needs (i.e. safety needs, love belonging needs).

Looking Forward
As the research base for subsequent adolescent childbearing continues to grow additional risk factors for the problem are being examined and added to the list. Recently new literature has emerged suggesting teens with low levels of parental behavior monitoring may be at the greatest risk for subsequent teen pregnancy (26). This research shifts the attention away from the individual risk factors of teenage girls and towards risk in the context of their family.

An adolescent subsequent pregnancy prevention program called Three Generations has put this research to practice in Baltimore, Maryland. The Three Generations program uses a home visitation model to discuss family planning and teach adolescent mothers and their adult parents/caregivers negotiation and decision making skills. The program was deemed a success when mothers in the control group were determined to be 2.5 times more likely to have given birth to a second child than mothers in the intervention group (27).

I propose that future interventions to reduce repeat pregnancies look to Three Generations as a program model. The program’s use of Social Cognitive Theory as their theoretical basis was both innovative and effective. Social Cognitive Theory is centered on the idea of self efficacy, the belief that one has the capabilities to execute the courses of action required to manage prospective situations (28). Instead of taking on an authoritative role with young mothers social cognitive theory based programs teach young families to take control of their own problems and decisions.

In conclusion, designing and implementing a program that addresses the unique needs of disadvantaged teen mothers is not an easy task. New Chance provided young mothers with many of the tools needed to establish self sufficiency; however the rigid structure of the program, the adolescent’s alternate perceptions of early childbearing and the lack of mental health services prohibited New Chance from achieving their intended outcomes.

References
1. Guttmacher Institute. Teenage Sexual and Reproductive Behavior in Developed Countries. New York: Guttmacher Institute. http://www.guttmacher.org/pubs/summaries/us_teens.pdf.
2. Guttmacher Institute. Teenage Sexual and Reproductive Behavior in Developed Countries. New York: Guttmacher Institute. http://www.guttmacher.org/pubs/summaries/us_teens.pdf.
3. Child Trends. Teen Birthrate Facts at a Glance. Washington DC: Child Trends. www.childtrends.org/Files/Facts_2005.pdf.
4. US Department of Health and Human Services. Understanding and improving health and objectives for improving health: reduce the proportion of births occurring within 24 months of a previous birth. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: US Government Printing Office, 2000:9-12–9-14.
5. Kalmuss D, Namerow P. Subsequent childbearing among teenage mothers: the determinants of a closely spaced second birth. Family Planning Perspectives 1994; 26(4): 149-53.
6. Koniak-Griffin D, Lesser J, et al. Teen pregnancy, motherhood, and unprotected sexual activity. Research in Nursing & Health 2003 26(1): 4-19.
7. Black, M. M., M. E. Bentley, et al. Delaying second births among adolescent mothers: a randomized, controlled trial of a home-based mentoring program. Pediatrics 2006 118(4): e1087-99.
8. Black, M. M., M. E. Bentley, et al. (2006). Lbid. Pediatrics 118(4): e1087-99.
9. Maynard R.A. (ed.), Kids Having Kids: A Robin Hood Foundation Special Report on the Costs of Adolescent Childbearing, New York: Robin Hood Foundation, 1996.
10. Maynard, R.A. (ed.), lbid. New York: Robin Hood Foundation, 1996.
11. Maynard, R.A. (ed.), lbid. New York: Robin Hood Foundation, 1996.
12. Maynard, R.A. (ed.), lbid. New York: Robin Hood Foundation, 1996.
13. The National Campaign to Prevent Teen Pregnancy. The Public Costs of Teen Childbearing. Washington DC: The National Campaign to Prevent Teen Pregnancy. http://www.teenpregnancy.org/works/pdf/Science_Says_30_costs.pdf
14. The National Campaign to Prevent Teen Pregnancy. The Public Costs of Teen Childbearing. Washington DC: The National Campaign to Prevent Teen Pregnancy. http://www.teenpregnancy.org/works/pdf/Science_Says_30_costs.pdf
15. The National Campaign to Prevent Teen Pregnancy. The Public Costs of Teen Childbearing. Washington DC: The National Campaign to Prevent Teen Pregnancy. http://www.teenpregnancy.org/works/pdf/Science_Says_30_costs.pdf
16. Maynard, R.A. (ed.), lbid. New York: Robin Hood Foundation, 1996.
17. American Youth Policy Forum. New Chance. New York: Manpower Demonstration Research Corporation. http://www.aypf.org/publications/compendium/C1S25.pdf .
18. Manpower Demonstration Research Corporation. Final Report on a Comprehensive Program for Young Mothers in Poverty and Their Children. New York: MDRC. http://www.mdrc.org/publications/145/execsum.html .
19. American Youth Policy Forum. New Chance. New York: Manpower Demonstration Research Corporation. http://www.aypf.org/publications/compendium/C1S25.pdf .
20. American Youth Policy Forum. New Chance. New York: Manpower Demonstration Research Corporation. http://www.aypf.org/publications/compendium/C1S25.pdf .
21. American Youth Policy Forum. New Chance. New York: Manpower Demonstration Research Corporation. http://www.aypf.org/publications/compendium/C1S25.pdf .
22. Klerman L, Baker B, et al. Second births among teenage mothers: program results and statistical methods. Journal of Adolescent Health 2003; 32(6): 452-5.
23. Black, M. M., M. E. Bentley, et al. Lbid. Pediatrics 2006; 118(4): e1087-99.
24. Black, M. M., M. E. Bentley, et al. Lbid. Pediatrics 2006; 118(4): e1087-99.
25. Manpower Demonstration Research Corporation. Final Report on a Comprehensive Program for Young Mothers in Poverty and Their Children. New York: MDRC. http://www.mdrc.org/publications/145/execsum.html .
26. Sieverding J, Adler N, Witt S, Ellen J. The Influence of Parental Monitoring on Adolescent Sexual Initiation. Pediatric Adolescent Med 2005; 159:724-729.
27. Klerman L, Baker B, et al. Second births among teenage mothers: program results and statistical methods. Journal of Adolescent Health 2003; 32(6): 452-5.
28. Wikipedia. Self Efficacy. Wikipedia Foundation. http://en.wikipedia.org/wiki/Self_efficacy.

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