When children have children: the teen pregnancy predicament.

Despite developments in contraceptive technology and changes in societal norms, adolescent pregnancy remains a key issue for politicians, social scientists, health care providers, and educators. The adolescent's access to contraception and abortion services continues to spark legal debate. The implications of research call for the development of innovative programs to address larger issues, such as poverty and limited access to health care, in the management and prevention of adolescent pregnancies. Clinical interventions, such as school-linked clinics to provide contraception and prenatal care programs to reduce perinatal morbidity, have varied in their approaches and their subsequent success.

PIP: The birthrate among both white and African-American US young women 15-19 years old declined steadily from 89.1 live births per 1000 women (LB/1000) in 1960 to 51.3 LB/1000 in 1985, as a result of the availability of contraception and abortion. The rate has since risen to 62.1 LB/1000 in 1991. In contrast, the birthrate among unmarried young women 15-19 years old increased from 15.3 LB/1000 in 1960 to 42.5 LB/1000 in 1990. The birthrate among white unmarried adolescents more than tripled over the past three decades. The Johns Hopkins University School of Public Health revealed a rise in overall sexual activity from 28% in 1972 to 50% in 1979 in interviews of a national sample of 15-19 year olds. After the Supreme Court decision in Roe v. Wade, 232,440 abortions were performed in 1973 to 15-19 year olds and that number rose to 444,780 by 1980. Title IX of the Civil Rights Act prohibited the exclusion of girls from schools on the basis of pregnancy. In 1977 the Supreme Court struck down a statute that prohibited the sale of nonprescription contraceptives to minors under 16. Reports by the Centers for Disease Control and Prevention identified 1,559,110 legal abortions in 1987, of which 26.1% were to women younger than 20 years old. The adolescent seeking an abortion faces clinical disclosure and parental consent. According to a 1985 poll, 85% of Americans approve of sex education. Nearly 60% of 12-17 year olds surveyed in 1986 said that they had taken a course or had a class on sex education. However, in a 1988 survey of over 4000 public school teachers, only 84% of teachers were in programs that included sexual decision making, abstinence, and birth control methods. Adolescent childbearing may represent normative behavior for those coping with the stress of poverty. Adolescent pregnancy is associated with low birthweight, preterm labor and delivery, poor maternal weight gain, hypertension, anemia, and sexually transmitted diseases.

A study of women requesting interval contraceptive sterilization who do and do not return for surgery.

With the use of initial records of 1128 women who presented for interval tubal ligation, characteristics of those who were sterilized were juxtaposed with characteristics of those who did not return for surgery. Follow-up telephone interviews were conducted to explore regret after sterilization among 268 sterilized women. The subsequent histories of 144 women who did not return for surgery were examined, to determine whether failure to return might have screened, selectively, the women at greatest risk of regret. High levels of subsequent unwanted conception and pregnancy wastage were found in the nonreturn group. Institutional factors were often implicated in failure to return. Variables available at initial presentation are proposed to identify women who risk adverse consequences of postponed sterilization, to facilitate return without increasing regret.

The effect of administration family planning policy on maternal and child health.

PIP: Several ideologies of the present Administration appear to converge as they impinge upon family planning--themes which are not restricted to reproductive health but which interact in ways particularly threatening to its achievements of the last decade. Most of these ideologies are clear, articulated objectives of the present government such as overall budget reduction and the return of budgetary control to the states. Others are responsive to the influence of the so called "moral mojority." Essentially, the federal government can affect family planning delivery through 4 different routes: through the allocation of funds; through specific legislation; and through regulation or organizational structure (areas in the hands of the executive branch alone). There have been recent and prime examples of all 4 routes, all directed at weakening the federal family planning program which has grown steadily stronger with bipartisan support in the last decades. Major sources of family planning support are reviewed in order to indicate the areas of change or of serious risk to the field. By retaining the categorical funding of Title 10 (half of the federal money in the family planning field has, for some years, come through Title 10 of the Public Health Service Act) in 1981, Congress reasserted the importance it places upon fertility regualtion against Administration pressure to block-grant. Despite an approximately 23% cut, this funding remains the single best hope for the field in these tight money times. In the language of the House Budget Committee report, Congress expressed its intention that an emphasis upon family planning be retained in the Maternal and Child Health block grant. It is no surprise that under the pressure of funding cuts that intention has not been honored. An upsurge in the use of Medicaid funding by family planning providers has increased the proportion of family planning funds from this source. In Title 20 of the Social Security Act (Social Services) it is permissible to support family planning but not mandatory as it has been in the past. Several legislative measures regarding abortion before Congress last year were not enacted, measures which might have been a serious threat to the provision of legal abortion. It is legislatively that abortion service is in most danger, with Administration forces committed to making it illegal under almost all conditions. Not all policies of this Administration are subject to control by the Congress. The parental notification regulations promulgated by the Department of Health and Human Services are an example of policy responsive to the concept that government can decide what is good for the American Family.^ieng

Adolescent sexual behavior and childbearing.

PIP: Low self esteem does not explain problems of adolescence, particularly unwanted pregnancy and early childbearing. This intimates that their root causes are personal rather than structural and socioeconomic, thereby allowing us to blame the victim. Contrary to popular opinion, few teens (10%) want to conceive and most teens want something other than pregnancy, indicating a need for effective intervention. Teens who were ambivalent about childbearing 2 years earlier are just as likely to have given birth as those who wanted to conceive. Teens self-concept is based on the reality of their environment, which, for most teens who have given birth, involves chronic unemployment, a culture of single parenthood in which men play no supportive role in the home, and the knowledge that teens who choose to continue to attend school despite having given birth fare the same as those who drop out of school. Structural changes (jobs and career goals), long term intervention, and continuous social support are needed to improve a teen's capacity to make choices, especially those concerning contraception. In other words, motivation must be so strong that conceptions are avoided. No family wants to go on welfare and no woman wants to have a baby while a teenager, but when teens become pregnant, they tend not to choose abortion. If welfare reform creates true opportunity for jobs, it will create the motivation to avoid pregnancy but not reduce the childbearing rate among teens that conceive. Very early maturation is correlated with very early onset of sexual activity. The very best sex education and services are unlikely to be offered at a young enough age in schools. US society is obsessed with and unwilling to talk about sex. The notion of choice is not part of poor America. Interactive interventions providing continuing support are needed to make a difference in adolescent pregnancy.^ieng

Addressing adolescent sexual behavior and childbearing: self-esteem or social change?

PIP: Although onset of sexual intercourse in adolescence without regard to marital status has become normative behavior in the US, teen childbearing (as opposed to abortion) is generally restricted to poor communities. A Baltimore study found that only 5% of low-income urban adolescents desired pregnancy; 47% unequivocally wanted to avoid pregnancy and 48% were ambivalent. However, normative pressures from the cultural milieu were inadequate to overcome these adolescents' ambivalence or resistance to teen parenthood. Socioeconomic factors impeding the ability of these teenagers to avert undesired childbearing included the observation that peers who complete high school and postpone motherhood are no better off financially at age 30 than those who do not, pessimism about the possibility of fulfilling one's dreams or even surviving into adulthood, and community indifference. Programs that seek to strengthen the self-esteem of female adolescents may be helpful in improving the capacity to make good choices, but are insufficient in the absence of changes in the cultural context in which these choices are formulated. As long as schools, housing, social services, and job opportunities in poor communities are comprised, teens cannot be expected to select education and jobs over early childbearing and welfare. Massive social change aimed at altering the life chances of low-income youth is an essential component of any strategy that seeks to reduce the rate of adolescent parenthood. This could involve tutoring, job training and placement, mentoring, and access to real alternatives. An emphasis on self-esteem building as a primary mechanism for effecting social change tends to perpetuate the faulty notion that individual rather than structural factors are responsible for social problems.^ieng

Reasons for delay in contraceptive clinic utilization. Adolescent clinic and nonclinic populations compared.

Because delay in accessing contraceptive services is a serious obstacle to prevention of unintended pregnancy in adolescence, reasons for delay are probed in a junior and senior high school population and compared with results obtained among 435 young black women previously surveyed in 32 U.S. clinics. The 388 students surveyed before exposure to pregnancy prevention services are compared with 422 surveyed after greater than or equal to 2 years exposure to a successful educational/clinical intervention program. Particular attention is paid to reasons cited by those who never utilized services; important reasons cited by all groups include fear that contraception is dangerous (cited by 40.0% at baseline), fear of parental discovery (30.5%), and awaiting "closer" partner relationships (31.3%). The last reason was often cited a year or more after initiating coitus. That the perception of birth control as dangerous is a barrier to contraception is confirmed by the large proportions who cited it among those who had never used clinical services. Programmatic implications of the findings are discussed.

Durations of adolescent sexual relationships before and after conception.

PURPOSE: To explore durations of young couples' relationships between meeting and first intercourse, before first conception and for two years following conception and the associations between these durations; to describe the association between these durations and the young women's perceptions of the nature of these relationships. METHODS: Three hundred and seven adolescent women were enrolled in a prospective study while presenting for pregnancy tests (the index event); they were followed for two years in three groups--those with negative tests, those who terminated the pregnancy and those who bore a child. Retrospective information about durations of relationships with first partners and partners at the index event was obtained at baseline; follow-up data was obtained on continuing relationships with the index partner. RESULTS: Durations of relationships between adolescent females and their partners in this sample, both before and after conception, are rarely brief; the median duration of a girl's prior relationship with a partner with whom she conceives is almost two years. Similarly, almost half of the sample is still in a relationship at two years following the index event, a proportion that rises to two-thirds among those who bore a child together. CONCLUSIONS: Contrary to common belief or practice, there may be sufficient time and commitment to include many male partners in intervention programs before, and in parenting programs after, a first conception--a practice which could have positive implications for both adolescent partners and, potentially, for their child.

Users of reproductive health clinic services in a school pregnancy prevention program.

Although the potential of school-based programs in the prevention of adolescent pregnancy is well recognized, few have been evaluated. This paper describes the use of a reproductive health care clinic associated with a school pregnancy prevention program which had demonstrated success. The program operated in one junior and one senior high school in a large city during the 3 school years from 1981 to 1984. Three facets of the 818 users of the program clinic are explored: who enrolled in the clinic, why they enrolled and what contraceptive methods they received, and their continuation with the clinic. Chi-square analysis and Student's t-tests were used to test for significant differences between the two school and sex groups. Life table and regression techniques were employed to examine clinic continuation. The main findings are teens of both sexes used the clinic, and junior high males used it in surprisingly large numbers; there were no major school or sex differences in the characteristics of those who enrolled; most students enrolled to obtain a contraceptive method; although many females served by the clinic had previously used another family planning clinic, the majority of them had unmet needs; the rate of clinic continuation was high; and certain factors contributed to clinic continuation. These findings suggest that a clinic in a school-linked setting can successfully attract students to use its services and it may offer certain advantages for reaching sexually active teens in search of contraceptive protection.

School-based programs to reduce sexual risk behaviors: a review of effectiveness.

This review was undertaken in recognition of the mounting public health and social problems associated with adolescent sexual behavior and the importance of basing school-affiliated programs designed to reduce sexual risk-taking behavior on sound research. The authors were commissioned by the Division of Adolescent and School Health within the Centers for Disease Control and Prevention, Public Health Service, to review carefully the research on these programs and to assess their impact on behavior. The authors identified 23 studies of school-based programs that were published in professional journals and measured program impact on behavior. They then summarized the results of those studies, identifying the distinguishing characteristics of effective programs, and citing important research questions to be addressed in the future. Not all sex and AIDS education programs had significant effects on adolescent sexual risk-taking behavior, but specific programs did delay the initiation of intercourse, reduce the frequency of intercourse, reduce the number of sexual partners, or increase the use of condoms or other contraceptives. These effective programs have the potential to reduce exposure to unintended pregnancy and sexually transmitted disease, including HIV infection. These programs should be replicated widely in U.S. schools. Additional research is needed to improve the effectiveness of programs and to clarify the most important characteristics of effective programs.

A school-, hospital- and university-based adolescent pregnancy prevention program. A cooperative design for service and research.

Based upon prior service and research findings, a program was designed to reduce the incidence of early childbearing among a high-risk, inner-city junior and senior high school population. Combining a strong research design with medical and educational service in a school- and clinic-based program, the project team sought to develop a replicable model the individual components of which could be evaluated against baseline data collected from 1,709 male and female students before the program began. This paper reports levels of sexual activity, contraceptive use and pregnancy in the student population, using data from anonymous, self-administered questionnaires, and outlines the program's objectives and major features. It also suggests variables that can be used in the measurement of program impact.

PIP: Based on prior service and research findings, a program was designed to reduce the incidence of early childbearing among a high-risk, inner-city, junior and senior high school population. Combining a strong research design with medical and educational service in a school and clinic based program, the project team sought to develop a replicable model the individual components of which could be evaluated against baselin data collected from 1709 male and female students before the program began. This paper reports levels of sexual activity, contraceptive use, and pregnancy in the student population, using data from anonymous, self-administered questionnaires, and outlines the program's objectives and major features. It also suggests variables which can be used in the measurement of program impact.

Abortion among adolescents: research findings and the current debate.

Utilizing research that focuses on adolescents as well as findings in samples which might have special relevance to young, unmarried women, this report summarizes research on the consequences of abortion among adolescents. It discusses prior literature in the area of parental notification and parental consent, subjects on which public opinion is not divided along familiar pro-choice/anti-choice lines. Following a discussion of methodological problems identified in prior research, it reports on a study designed to address these problems in an adolescent population; it discusses implications for the current debate of this and other studies' findings that there are no identifiable adverse sequelae of the abortion process.

PIP: The abortion rate among U.S. teens has increased from 43/1,000 in 1981 to 46/1,000 in 1988, with abortions among teens accounting for 25% of total abortions in the U.s. These rates are significantly higher than those in Canada, England, France, Sweden, and the Netherlands which ranged over 5-26/1,000 in 1981. Prior studies of the physical and psychological consequences of abortions among teens almost unanimously indicate that negative sequelae do not exist. This paper summarizes research on the consequences of abortion among adolescents and discusses literature on parental notification and parental consent. Methodological problems found in prior research are also discussed, followed by a report on a Johns Hopkins University study designed to address these problems in an adolescent population. The Johns Hopkins study supports prior research demonstrating the lack of significant sequelae to abortion among teenage women. The medical consequences of childbearing are worse than those of abortion at all stages of gestation, while abortion even offers considerable advantages in the economic and educational areas. In contrast to mandated parental involvement proposed by the Bush administration, teenage women should be allowed the freedom to choose the less dangerous option of abortion without parental consent just as they are allowed to choose to bear children.

Marital and birth expectations of urban adolescents.

PIP: The formation of attitudes conducive to pregnancy prevention is usually included in the development of adolescent pregnancy prevention programs. This research examines the marital and birth expectations among 3646 adolescents enrolled in grades 7-12 in four inner city schools in 1981-82 in the US. The aim is to assess adolescents' perceptions of life experiences in their social environment, which reveal their beliefs about the social acceptability of birth after marriage. Two of the schools had entirely Black student populations, and two for comparison purposes had a mixed student population comprised of 33% Black students. Results reveal that Blacks reported a higher age for marriage and a lower age of first birth than Whites. Blacks had a lower mean ideal age of first birth than for marriage, while White had a lower mean age of marriage than for first birth. 59.1% of Black teenage females and 55% of Black teenage males reported a first birth ideal less than the marriage age, while 20.4% of White teenage females and 21.1% of White teenage males did so. A comparative graph shows Whites having in-wedlock births around 21 years of age and Blacks having in-wedlock births at 26 years of age. The analysis of the best age of marriage regressed on the best age at first birth indicates that the slopes are parallel, and there is no significant difference between Black and White attitudes. Blacks had an ideal marriage age of about two years later than Whites. In the comparison of survey responses to vital statistics data on legitimacy of first births in Baltimore in 1980, it appears that there is a close correspondence between actual out-of-wedlock status of first births and female adolescent attitudes. This study's findings suggest that both Blacks and Whites expect early births to be premarital and later births to be postmarital. Adolescent experiences affect their perceptions, and teenagers' perceptions are fairly realistic. The interpretation of findings is that Black-White differences reflect both macro-historical change and the microlevel community experiences of young people. Findings support Espenshade's historical analysis. Educational interventions should account for the facts that teenagers' ideal age for marriage is older than their projected ages of first births and that beliefs are influenced by community norms.^ieng

The school-based approach to teen pregnancy prevention.

PIP: A pregnancy prevention project, a collaborative school- and clinic-based program serving 2 Baltimore inner-city, all black schools, delivered reproductive health services at a special clinic close to the schools, while education and counseling int he clinic and in the schools utilized the same staff. The junior high and senior high was attended by more than 1700 male and female students. A social worker and a nurse practitioner were placed in each school to give classroom lectures and to meet with individuals and groups during the school day. In the afternoon they were in the clinic, where information rap sessions, private counseling and consultation, medical services, and educational programs were available. Responsible sexual behavior was emphasized along with postponement of sexual intercourse, open communication with parents, and placing sexual conduct in the context of personal goals and values. Both males and females could enroll in the clinic. Regardless of whether they registered for services, they were welcome to come to talk in the waiting room, to see films, or to enter group discussions. They were eligible for services, all of which were free, as long as they remained in 1 of the 2 schools. Thus, educational and medical interventions were accessible to these school populations, and the unified professional staff provided continuity for the students between the school and clinic programs. The privately funded intervention began in November 1981, with the clinic opening a few months later. It lasted for 3 academic years, or 28 months of clinic operation. To evaluate the program, data were collected by self-administered questionnaire 4 times in the program schools: before the program began and at the end of each of the 3 program years. All male and female students were asked to complete the detailed questionnaire on a broad range of sexual knowledge, attitudes, and behaviors. Data also were collected at a nonprogram junior and senior high school, as well matched as possible to the study schools. There were significant increases in the level of sexual and contraceptive knowledge. Attitudinal change was not as great. There was not much room for change, since generally positive attitudes were found toward contraceptive and negative attitudes toward adolescent reproduction even befor the program began. The program's largest effect was on clinic attendance, for boys and girls alike. So successful was the program at attracting junior high school boys that their attendance paralleled senior high school females' use of clinic facilities prior to the program's onset. For girls, too, attendance soared, resulting in a level of contraceptive protection, even at young ages, which was markedly improved. Fewer than 20% in each grade were unprotected at last intercourse after 2 or more years of program exposure. In contrast, in the nonprogram schools most grades reported 44-49% unprotected at last coitus.^ieng

The impact of early use of prescription contraceptives on reducing premarital teenage pregnancies.

PIP: Examines the potential impact of early use of medically prescribed contraceptives on reducing premarital pregnancies among teenagers. If all teenagers began using a prescription method 1 month after initiating intercourse, the risk of premarital pregnancy would be reduced by 40% from actual levels, from 35% within 2 years to 21%. The fact that 21% would still get pregnant is attributed to the very high risk of pregnancy following a 1st unprotected intercourse and to inconsistent or ineffective use of methods and their discontinuation.^ieng

Adolescent pregnancy: the clinician's role in intervention.

Adolescent childbearing has adverse sequelae that are intensified when the onset of sexual activity takes place at a particularly early age. A relationship between the onset of sexual activity and the age of maturation has been demonstrated; as the mean age of menarche has become younger, a greater discontinuity has been created between physical development on the one hand and cognitive and emotional development on the other. Initiatives to prevent early sexual initiation and unintended pregnancy must be designed in that context and with an appreciation of normative social pressures. This report reviews research on adolescent development and sexual behavior, including the relationship between maturation and the onset of sexual activity, the timing of pregnancy risk, clinic utilization and reasons for delay in clinic attendance, and clusters of high-risk behaviors. It discusses the role of clinical interventions, suggesting ways in which those who treat adolescents can assist them in acquiring and maintaining protective behaviors.

The association between smoking and sexual behavior among teens in US contraceptive clinics.

A study of teenage women in 32 contraceptive clinics in the United States shows a strong negative relationship between age of first intercourse and the level of cigarette smoking; the association is strong enough to reverse the usual correlation of smoking and age during the teenage years. Preventive, timely contraceptive behavior is also negatively associated to smoking. These findings suggest that interventions could well be designed and located in settings which take this association into account.

Does the timing of the first family planning visit still matter?

CONTEXT: The timing of a first family planning visit relative to first intercourse can affect the likelihood of an early unintended pregnancy. METHODS: Nationally representative data from the 1982, 1988 and 1995 cycles of the National Survey of Family Growth were used to examine changes in the timing of first family planning visits and to explore the degree to which young women are now more likely than in the past to practice contraception independently of making a visit to a provider. Cox proportional hazards models were used to estimate how background variables, visit status and the initiation of contraceptive use affected risks of unintended pregnancy in the four years preceding each survey. RESULTS: The proportion of women who waited a month or more after their first intercourse to see a provider grew slightly between 1978 and 1995, from 76% to 79%; women waited a median of 22 months after first intercourse in 1991-1995. Any contraceptive use at first intercourse increased among both women who delayed a first visit (from 51% to 75%) and among those whose first visit occurred before their first intercourse or within the same month (from 61% to 91%). Cox proportional hazards analysis suggests that the protective effect of a first family planning visit decreased over the period studied, due in part to the increase in early contraceptive use. CONCLUSIONS: The importance of the first family planning visit appears to be declining, as sexually active young women who delay their first visit increasingly do so because they are already using a provider-independent method (primarily the condom). Thus, a multifaceted approach to providing family planning may now be needed, in which independent method use and visits to providers both play a role.

PIP: The timing of a first family planning visit relative to first intercourse can affect the likelihood of an early unintended pregnancy. Nationally representative data from the 1982, 1988, and 1995 cycles of the National Survey of Family Growth were studied to identify changes in the timing of first family planning visits and to investigate the degree to which young women are now more likely than in the past to practice contraception independently of visiting a provider. The proportion of women who waited a month or more after their first intercourse to see a provider grew from 76% to 79% between 1978 and 1995, with women waiting for a median of 22 months after first intercourse in 1991-95. Any contraceptive use at first intercourse increased among women who delayed a first visit from 51% to 75%, and among those whose first visit occurred before their first intercourse or within the same month from 61% to 91%. The importance of the first family planning visit seems to be declining, as sexually active young women who delay their first visit increasingly do so because they are already using a provider-independent method, mainly the condom. This greater use of the condom is related to the advent of the HIV/AIDS pandemic and the associated broader awareness of condoms' ability to block the transmission of HIV and other STDs.

The health consequences of adolescent sexual and fertility behavior in sub-Saharan Africa.

This article reviews the literature on health consequences of adolescent sexual behavior and child-bearing in sub-Saharan Africa, and the social and cultural context in which they occur. It suggests that, in addressing the most serious health sequelae, sexual intercourse that occurs in early marriage and premaritally must both be considered. Some limitations of the data are noted. Despite the excess risk to which adolescents are exposed, due both to custom and age-related vulnerability, differences between health effects among adult and adolescent women are often differences in degree. They are attributable to behavioral, social, and biological causes, exist in traditional and nontraditional settings, in union and out of union, and are exacerbated by declining ages at menarche, pressures of HIV/AIDS and STDs, and a dearth of appropriate services-especially for young people. Some current interventions are discussed, and the need for policy as well as medical intervention is stressed.

PIP: A review of the literature on the health consequences of adolescent sexual behavior and childbearing in sub-Saharan Africa reveals substantial contextual variation. Among the more general factors impacting on early sexual onset and childbirth are younger age at menarche, erosion of social and cultural controls on premarital sex, the abandonment of pubertal rites of passage, and more widespread schooling. Childbearing at young ages has been associated with pregnancy-induced high blood pressure, anemia and hemorrhage, obstructed and prolonged labor, infection, and higher rates of infant morbidity and mortality. Both cultural and biologic factors elevate the likelihood of transmission of sexually transmitted diseases, including HIV, among female adolescents. Many sequelae common to all adolescents are exacerbated by cultural practices such as genital mutilation. It is often assumed that the health problems of adolescent females will be addressed by general improvements in women's health services. However, the level of care required by adolescents who are delivering a first child is considerably greater than that required by healthy adult women. Moreover, may women's health services are hostile to teens who initiate coitus out of wedlock and may even deny treatment. Ultimately, prevention may depend more on changes in public policy and consideration of cultural context than upon specific programs.

Why they delay: a study of teenage family planning clinic patients.

PIP: Teenagers wait an average of about 1 year before seeking birth control help at a family planning clinic. Nearly 4 in 10 teens come to the clinic only because they fear they are pregnant; only 1 in 7 come for help in anticipation of their 1st sexual encounter. While 3/4 use a nonprescription method at some time before they arrive at the clinic, most use methods of doubtful effectiveness and 1/2 of these used no method at last intercouse. Blacks are more likely than whites to come to the clinic as virgins or soon after beginning intercourse. Fear of pregnancy is the main reason given for finally going to the clinic, and fear that the family would find out was often mentioned. Shorter delays found among users of nonmedical methods suggest that initiative to expand and improve such usage may help teenagers prevent pregnancies during the early part of their sexual careers and also accelerate their adoption of more effective methods. If clinics become known as a source of free supplies of nonprescription methods as well as of general contraceptive advice, they might be more utilized by teenagers earlier. Thorough counseling about these methods as a backup to prescription methods is also needed. The importance of emphasizing confidentiality is noted, although it is also noted that teenagers who are able to talk to their parents about such matters are more likely to come to the clinic before or soon after they begin having intercourse. Data came from a 1980 survey of a wide range of family planning services in 8 cities, representing over 1200 adolescents.^ieng

Institutional factors affecting teenagers' choice and reasons for delay in attending a family planning clinic.

PIP: This study explores the reasons why teenagers coming for professional birth control help for the 1st time choose the particular clinic in which they enrolled and the clinic characteristics which may encourage the young patients to come for contraceptive help early or contribute to a delay in seeking services. 1234 never pregnant teenagers in 31 family planning clinics of various types in 8 cities answered a questionnaire in the spring of 1980. About 44% of the respondents were white, 48% black and the rest from other racial groups. Just over 14% came to the clinic before 1st coitus, 36% came only because they suspected they were pregnant, and the rest enrolled after they began intercourse but did not suspect pregnancy. The interval between intercourse and enrollment ranged from a few weeks to 2 years with a median interval of 11.5 months. There were 15 possible responses to the question, "Why did you choose this clinic?" The 5 principal reasons given in order were: It doesn't tell their parents; the people there care about teens; it is the closest, their friends come to it; and it is the only 1 they know of. Also significant was, for blacks only, an adult, usually the mother, chose the clinic. Additional information on responses to this question and others is given in charts. The questionnaire also showed a consistent but weak association between the reasons for selecting a particular facility and the characteristics of the clinic such as cost of services, special teen hours, teen rap sessions, and outreach program. The responses indicated that many factors including age, race, and the time when the teenager 1st seeks clinic services affect her choice. The conclusion drawn is that a network of facilities with a variety of services is needed with the common characteristics of open caring atmosphere, women clinicians available and absolute confidentiality so that the proportion of young women who appear only after they are pregnant might be greatly reduced.^ieng