Ambivalence and pregnancy: adolescents' attitudes, contraceptive use and pregnancy.

The majority of pregnancies among unmarried teenagers are unintended. (1) Most adolescents do not want to become pregnant, although some are not opposed to becoming pregnant and others have ambivalent attitudes. (2) A number of explanations of why adolescents' attitudes toward pregnancy vary exist in the literature; however, less often considered is whether these attitudes are associated with pregnancy risk and contraceptive use.

Questions about the relevance of attitudes are important because attitudes may mediate the often-observed association between socioeconomic disadvantage and pregnancy risk. For this reason, social policy is often oriented toward shaping attitudes. Many researchers and advocates have argued that teenage pregnancy prevention programs should target attitudes toward pregnancy. (3) One reason for the attention to pregnancy attitudes has been that interventions that increase the availability of contraceptives have experienced uneven success in reducing teenage pregnancy rates. (4) Many experts have concluded that adolescents have access to the means to avoid pregnancy but do not use them or use them inefficiently because they do not appreciate the consequences of pregnancy. (5)

Actors in the social policy domain may also focus on teenagers' attitudes because they seem easier to change than the social and economic conditions in which those attitudes develop. For example, poverty is associated with teenage initiation of sex, nonuse of condoms at first intercourse and accidental pregnancy, (6) but pregnancy intervention programs are not well suited to end poverty. They may, however, be well suited to shape attitudes. But which attitudes? In the current political climate, supporting programs designed to shift attitudes about pregnancy is easier than supporting programs designed to shift attitudes about contraception. In this article, we address whether sexually experienced adolescents' attitudes toward pregnancy influence their risk of becoming pregnant.

Adolescent Contraceptive Use and Pregnancy

An extensive literature documents the determinants of adolescent contraceptive behavior. Critical factors associated with contraceptive use include social and demographic characteristics (e.g., age, race and income), family-related characteristics (e.g., parental education and closeness with parents) and individual characteristics (e.g., cognitive ability, educational achievement and expectations, self-esteem, age at first sex, history of pregnancy and attitudes toward contraception). (7) The impact of religiosity on contraceptive use is less clear, and the literature contains mixed results about the effects of adolescents' knowledge of sex, fertility and contraception.

With respect to pregnancy, the literature reports similar critical determinants. (8) Social and demographic predictors include age, race, income and parental education; family-related predictors include family structure and relationship with parents; and individual predictors include low cognitive ability, low educational expectations and achievement, negative attitudes toward school, lack of involvement in school clubs and problem behaviors. Popularity at school does not predict adolescent females' risk of pregnancy, but the characteristics of their friends do. Finally, number of partners, age at onset of sexual activity and contraceptive behavior are strong predictors of pregnancy risk.

Most studies that are concerned with attitudes toward pregnancy rely on small convenience samples or on retrospective accounts of pregnant adolescents' attitudes, which may be colored by the pregnancy. Jaccard et al. examined the role of attitudes toward pregnancy prospectively with a representative sample of sexually experienced and inexperienced adolescent females, and found a robust association between positive attitudes and subsequent pregnancies. (9) However, attitudes toward pregnancy are likely to be strongly correlated with attitudes toward having sex, which were not controlled for in the study's multivariate model. Thus, the finding maybe due to this omitted variable or to other factors that are correlated with pregnancy attitudes and delay in sexual debut.

We expand on the prior research in several ways. First, we limited our sample to sexually experienced young women, which allows us to assess the role of pregnancy attitudes in the absence of factors associated with the timing of sexual debut but not pregnancy risk. Because the majority of adolescents will become sexually active between the ages of 15 and 19, it is important for educators and policymakers to know whether attitudes toward pregnancy are associated with pregnancy risk among sexually experienced adolescents. Second, we explore whether contraceptive use is the behavioral mechanism that links attitude and outcome. It has been argued that ambivalence toward pregnancy is a risk factor for pregnancy because it leads to inconsistent contraceptive use, (10) but few studies have directly tested this idea.* (11) Finally, we examine the antecedents of attitudes toward pregnancy, paying special attention to the characteristics of adolescent women who lack a clear opinion.

METHODS

Data

We used data from the National Longitudinal Study of Adolescent Health (Add Health) because of its significant advantages over competing data sets. First, researchers have argued for the need to analyze prospective measures of pregnancy attitudes. (12) Exploiting the prospective features of Add Health allows us to rule out a reverse effect of behaviors (such as becoming pregnant) on attitudes. Second, the range of Add Health data allows us to include in our multivariate models detailed measures of well-established antecedents of both adolescent attitudes toward contraception and pregnancy, and adolescent contraceptive use and pregnancy risk. Finally, Add Health is a nationally representative study; adolescents are not selected on the basis of failed contraceptive use, as is the case in many clinic-based studies.

Add Health utilizes a multistage clustered sample design, and for this study, we used data drawn from its in-home components. (13) From May through December 1995, Wave 1 in-home interviews were administered to 20,745 adolescents. The interviews took 90 minutes to complete, on average, and collected detailed information about risk behaviors, romantic partnerships, family dynamics, aspirations, attitudes and activities. Eighty percent of adolescents in the initial sample completed a Wave 1 interview. Audio computer-assisted self-interviewing technology was used for questions covering sexual and other sensitive health behaviors. Between April and September 1996, re-interviews with Wave 1 respondents, excluding high school seniors, were conducted. Some 88% of eligible respondents participated in Wave 2, yielding a sample of 14,738 adolescents who completed both interviews.

Female respondents aged 15-19 who participated in both in-home interviews were eligible for inclusion in our analyses; we excluded those younger than 15 because they were not asked the questions about pregnancy attitudes. Also, we excluded 44 respondents who were married at Wave 1 or got married between waves, and 138 who were missing information on pregnancy attitudes or sexual history. The final sample consisted of 4,877 adolescent females.

Measures

* Attitudes toward pregnancy In the Wave 1 interviews, adolescents were asked how they would feel if they be came pregnant To measure pregnancy attitudes, we used five survey items that assessed adolescents' perceptions of the consequences of pregnancy: "if you got pregnant, it would be embarrassing lot your family"; "If you got pregnant, it would be embarrassing for you"; "If you got pregnant, you would have to decide whether or not to have the baby, and that would be stressful and difficult"; "If you got pregnant, you would be forced to grow' up too fast"; and "Getting pregnant at this time is one of the worst things that could happen to you." Response categories were strongly agree, agree, neither agree nor disagree, disagree and strongly disagree.

When the five responses were averaged into a single index of pregnancy attitude (Cronbach's alpha=0.72), this measure had relatively little dispersion (standard deviation=0.09) around its mean (2.1). Most respondents opposed pregnancy, although some respondents did so more vehemently than others, and still others appeared not to oppose it all. Yet another group of respondents were unable to form an opinion and chose "neither agree nor disagree."

We divided respondents into four groups according to their attitudes toward pregnancy. Those who strongly agreed with all five statements, or strongly agreed with four and agreed with one, were classified as having the most unfavorable attitudes toward becoming pregnant (antipregnancy). Respondents who disagreed or strongly disagreed with at least three statements were classified as having the most favorable attitudes toward becoming pregnant (propregnancy). Those who neither agreed nor disagreed with at least two statements were classified as having the least defined attitudes toward becoming pregnant (ambivalent). We categorized the 15 respondents who qualified as both ambivalent and propregnancy as propregnancy. The remaining respondents were considered to have mainstream attitudes.

Our analytic strategy was to define groups outside the mainstream that would be small enough to be considered extreme in attitude, but large enough to exhibit sufficient within-group variation. These group definitions are robust. Multiple adjustments to the groups (i.e., restriction and relaxation of the criteria) did not alter the relationship between attitudes and contraceptive behaviors or the occurrence of pregnancy in multivariate analyses. (#)

* Background characteristics. We controlled for age, race and ethnicity, maternal education, poverty status, family structure, closeness with mother, religiosity, cognitive ability, self-esteem and social isolation (Table 1). In addition, we created a measure of risk status adolescents' orientation to school, future expectations and nonnormative social behavior-from the cross-classification of two indices, as was done in a previous study. 14 The first index summarizes orientation to school, and includes grade point average, school attachment, number of extracurricular activities, and desire for and perceived likelihood of attending college. The second index summarizes nonnormative social behavior, and includes drinking, truancy, delinquency and having trouble with teachers or other students. We defined respondents who scored in the bottom quartile on the school orientation index and in the top quartile on the nonnormative social behavior index as being high-risk, and those who scored in the top quartile on the school orientation index and in the bottom quartile on the nonnormative social behavior index as being low-risk. The remaining respondents (the majority) were defined as middle-risk.

* Sexual behavior, contraceptive use and contraceptive knowledge. We considered respondents sexually experienced if they reported at Wave 1 that they had ever had sexual intercourse. Length of sexual career was measured as the difference between respondents' age at sexual debut and their age at Wave 2. We defined respondents' number of partners as the number of sexual partners they reported having between Waves 1 and 2, excluding any partners who were current at Wave 1. If a respondent reported at Wave 1 that she had ever been pregnant, she was considered to have had a prior pregnancy. Only pregnancies that occurred between waves were used to construct the outcome measure: pregnancies that had occurred prior to Wave 1 were used as a predictor of between-wave pregnancy.

We assessed respondents' knowledge about pregnancy avoidance at Wave 1 by their responses to nine true-or-false questions about proper condom usage, ovulation and pregnancy risk. In addition, we used the number of questions that a respondent answered incorrectly but was certain she had gotten right as a measure of respondents' unfounded certainty about pregnancy avoidance.

The questionnaire contained seven items that measured attitudes toward contraception. We constructed a scale from these items by averaging responses, which were given on a five-point Likert scale. Higher values indicate more positive attitudes toward contraception (Cronbach's alpha= 0.81).

Contraceptive behavior was measured retrospectively at Wave 2. Respondents were asked to report on up to six sexual relationships and, for each relationship, whether they used contraceptives, which methods they used and their contraceptive consistency (always, sometimes or never). To make sure that we measured the independent variables (e.g., attitudes) before the outcome occurred, only sexual relationships initiated between waves were included in the analysis.

For the analysis of pregnancy, we characterized contraceptive behavior differently for respondents who did not get pregnant between waves and those who did, to allow for the possibility that a pregnant respondent's contraceptive behavior was influenced by her pregnancy. For respondents who became pregnant, contraceptive behavior was characterized by use during the month in which the pregnancy occurred. To create a similar "worst-case" measure for respondents who did not get pregnant, contraceptive behavior was summarized across all interwave sexual relationships. Respondents were considered nonusers if they had not practiced contraception in at least one relationship. Among respondents who had practiced contraception in all their relationships, those who had used contraceptives inconsistently in at least one relationship were classified as inconsistent users, and those who always used contraceptives in every relationship were classified as consistent users.

Analysis

Because sexual experience is closely related to the outcomes of interest, we considered separately respondents who were not sexually experienced at Wave 1 and those who were. This allowed us to disentangle associations with timing of sexual debut from direct associations with pregnancy risk. We selected just those respondents who had had sex between waves and did not become pregnant, and examined the association between their attitudes toward pregnancy and their contraceptive behavior. Furthermore, we looked at the relationship of pregnancy attitudes to the occurrence of pregnancy among sexually experienced respondents. For each outcome, we began with bivariate analyses, using t-tests or analysis of variance for continuous variables and chi-square tests for categorical variables. Then, to explore whether the effect of pregnancy attitudes is mediated or suppressed by other predictors of the outcome in question, we used multivariate analyses, including the most important predictors identified in the literature. We adjusted the standard errors for the clustered sample design of Add Health. (15)

RESULTS

Attitude Toward Pregnancy

Of the 4,877 respondents, 57% had mainstream attitudes, 20% had antipregnancy attitudes, 8% had propregnancy attitudes and 14% were ambivalent. Overall, 44% of respondents were sexually experienced. Forty-one percent of the respondents in the mainstream group were sexually experienced; a significantly smaller proportion of those in the antipregnancy group (32%) and significantly greater proportions of those in the ambivalent (53%) and propregnancy (72%) groups were sexually experienced.

When we compared respondents' characteristics by their attitudes toward pregnancy, we found pronounced differences among the four groups in virtually every characteristic. In general, antipregnancy respondents enjoyed the greatest social advantages and personal assets, followed by mainstream, ambivalent and finally propregnancy respondents. (Table 2, page 251). Respondents with antipregnancy attitudes had the highest mean maternal education, maternal closeness, cognitive ability and self-esteem, and the most positive attitude toward contraception. In addition, greater proportions of those in the antipregnancy group than of others reported living with two biological parents and were considered low-risk. In contrast, respondents in the propregnancy group had the lowest mean maternal education, cognitive ability and knowledge of pregnancy avoidance, and the highest mean unfounded certainty about pregnancy avoidance. In addition, greater proportions of those in the propregnancy group than of others reported being poor or low-income, and were considered high-risk. Furthermore, among sexually experienced respondents, those who were propregnancy had the highest rate of previous pregnancy: Some 43% had had a pregnancy prior to Wave 1, compared with 21% of ambivalent respondents, 16% of mainstream respondents and 7% of antipregnancy respondents. A greater proportion of respondents who had had a prior pregnancy than of those who had not were antipregnancy (not shown); for this group, having a pregnancy may have led to a positive attitude toward pregnancy, rather than vice versa.

Attitude and Contraceptive Consistency

After weighting was applied, 1,415 sexually experienced respondents at Wave 2 answered questions regarding contraceptive behavior for at least one sexual relationship that began after Wave 1. Of these, 228 became pregnant between waves, leaving 1,187 respondents for the analysis of the influence of pregnancy attitudes on consistency of contraceptive use. **

Overall, 57% used contraceptives consistently, and an additional 16% inconsistently (Table 3); 27% of the respondents did not practice contraception at all. Although differences between mainstream (25%), antipregnancy (24%) and propregnancy (28%) respondents were nonsignificant, a greater proportion of ambivalent respondents (35%) than of those in other groups did not practice contraception (not shown). Compared with nonusers, a significantly greater proportion of inconsistent users were low-risk (21% vs. 13%), and a smaller proportion were Hispanic (4% vs. 10%); on average, inconsistent users had more positive attitudes toward contraception and had had fewer sexual partners. A greater proportion of consistent users than of nonusers were low-risk (25% vs. 13%), and smaller proportions reported an other family structure (4% vs. 8%), were high-risk (40% vs. 52%) or had had a previous pregnancy (6% vs. 12%). On average, consistent users had higher cognitive ability and self-esteem, and more positive attitudes toward contraception than nonusers, but they had had a shorter sexual career and fewer sexual partners.

The only difference between contraceptive users' and nonusers' attitudes toward pregnancy was in regard to ambivalence. A significantly greater proportion of nonusers than of inconsistent users reported feeling ambivalent toward pregnancy (17% vs. 10%). In contrast, attitudes toward contraception were strongly associated with contraceptive use: Those who used contraceptives consistently had the most positive attitude, followed by those who used it inconsistently and, finally, nonusers.

In multinomial logistic regression analyses, female adolescents differed significantly in their odds of being inconsistent or consistent contraceptive users (versus nonusers) according to certain characteristics (Table 4, page 253). Low risk status and having positive attitudes toward contraception were associated with increased odds of inconsistent or consistent contraceptive use (odds ratios, 1.6 2.1), and greater number of sexual partners was associated with decreased odds of contraceptive use (0.3-0.4). We found a curvilinear relationship between cognitive ability and likelihood of consistent and inconsistent contraceptive use, similar to that previously described for sexual debut. (16) Up to a point, greater cognitive ability increases the odds of using contraceptives, but for the smartest respondents, the likelihood decreases again. Thus, among the smartest adolescents, those who have sex tend to have risky sex. Most important, in comparison to respondents with mainstream attitudes toward pregnancy, those who felt ambivalent toward pregnancy had significantly reduced odds of using contraceptives inconsistently (0.4) or consistently (0.5).

In further analyses, we asked what differentiates consistent from inconsistent users (not shown). Pregnancy attitude was not significant. The only factor that was significantly associated with consistency was risk status: High-risk adolescents were less likely than middle-risk adolescents to be consistent rather than inconsistent users (0.6). This is interesting in light of our findings that being low-risk increased the odds of inconsistent use as opposed to no use. Being high-risk did not make respondents less likely to use contraceptives, but it made users less likely to be consistent users.

Attitude and Pregnancy

Respondents who became pregnant between Wave 1 and Wave 2 differed from those who did not in many respects (Table 5). (##) Greater proportions of adolescents who became pregnant than of those who did not were black or Hispanic, lived in an other family structure and were high-risk On average, they had lower maternal closeness and cognitive ability scores, and their mothers were less educated. A greater proportion of respondents who became pregnant than of those who did not had had a prior pregnancy at Wave 1. In addition, they were far less likely to have used contraception: Fifteen percent of respondents who reported a pregnancy between waves used contraceptives consistently, compared with 57% of those who did not become pregnant. And although respondents who became pregnant were as knowledgeable about pregnancy avoidance as others, they more often were certain that they answered questions about pregnancy avoidance correctly when they were, in fact, wrong There were no significant differences between the respondents who got pregnant and those who did not in their attitudes toward becoming pregnant.

In multivariate analyses, respondents' attitudes toward pregnancy were not significantly associated with the risk of pregnancy (Table 6). Living with a single parent doubled the odds, and being Hispanic more than doubled the odds of becoming pregnant between waves. Each increment in the AHPVT score increased the odds of becoming pregnant; as we observed in the analyses of contraceptive use, the relationship between cognitive ability and pregnancy is curvilinear. Contraceptive use was by far the most powerful predictor of pregnancy in the multivariate context: In comparison with consistent users, inconsistent users had 2.8 times and nonusers had 11.4 times the odds of becoming pregnant.

One would expect that respondents on polar ends of the opinion spectrum (i.e., those most opposed to and most in favor of pregnancy) would differ from each other in their risk of pregnancy. To assess this possibility, we used a Wald test for the equality of their respective coefficients in the pregnancy model. The result was nonsignificant, suggesting that attitudes toward pregnancy do not affect the likelihood of its occurrence. Finally, we constructed a model without the contraceptive consistency measures to test whether attitudes toward pregnancy were mediated by contraceptive use. The attitude coefficients did not change, and they did not become significant. Consequently, we found no support for the idea that such indirect effects were operating, and no evidence that pregnancy attitudes influence adolescent pregnancy outcomes via contraceptive behavior.

DISCUSSION

This study suggests that sexually experienced adolescents' attitudes toward pregnancy do not influence their subsequent risk of pregnancy. Because this finding appears to contradict previous research, (17) we conducted extensive sensitivity analyses. The difference rests on the definition of our sample, which excludes adolescents who had never had sex. Thus, the findings are not contradictory; rather, our results elaborate on the previous findings.

The results reported here are robust across multiple specifications. Specifically, more stringent criteria for defining the propregnancy and antipregnancy groups did not affect the association between attitudes and contraceptive consistency or pregnancy in multivariate analyses. Attempts to represent pregnancy attitudes through any alternative uses of the five survey questions about pregnancy also failed to change our results. Likewise, a summary index that averaged responses to all live questions bore no relationship to pregnancy. Finally, representing pregnancy attitudes as categorical variables did not alter the conclusions. The results are not an artifact of our measurement of pregnancy attitudes. In contrast, attitudes toward contraception have a strong impact on contraceptive use and, therefore, a strong impact on pregnancy.

Pregnancy attitudes appear to be subtly linked to contraceptive use, insofar as respondents with ambivalent attitudes are less likely than respondents with mainstream attitudes to practice contraception. Our definition of ambivalence is intended to capture the failure to form an opinion, rather than the presence of conflicting opinions. If ambivalent respondents were conflicted and merely less in favor of pregnancy than propregnancy respondents, the latter should be even less likely to use contraceptives. That they are not suggests that ambivalent respondents are a meaningfully distinct group. Their ambivalence does not represent the midpoint of a continuum of attitudes toward pregnancy, but rather absence front the continuum because of their inability to form an attitude at all. Because ambivalence about pregnancy is associated with contraceptive use, and contraceptive use is strongly associated with pregnancy, programs that focus on shaping attitudes toward pregnancy can be effective. Still, attitudes toward contraception are b> far the most important element.

Nevertheless, we cannot conclude that because we found no association between attitudes toward pregnancy and the risk of pregnancy that these attitudes are inconsequential. Attitudes toward pregnancy may express themselves by encouraging or discouraging respondents to have sexual intercourse. (18) In our sample, we find a strong bivariate association between attitudes toward pregnancy and being sexually experienced. Future research should examine this question with the appropriate prospective research design. Among respondents who have sex (the majority of adolescents in this age-group), variations in attitudes toward pregnancy do not predict the occurrence of pregnancy. ([dagger])

The factor most strongly associated with the risk of pregnancy among young women is contraceptive use, with nonusers being significantly more likely than inconsistent and consistent users to become pregnant; this finding is consistent with the results from previous research. (19) Factors associated with contraceptive use (regardless of consistency) include cognitive ability, number of sexual partners, attitudes toward contraception, being ambivalent toward pregnancy and being low-risk. The only predictor of consistent contraceptive use, as opposed to inconsistent use, was risk status.

These findings have implications for future attempts to reduce adolescent pregnancy. First, they suggest that targeting the pregnancy attitudes of sexually experienced female adolescents is not likely to be an effective means of discouraging pregnancy. Respondents with the strongest antipregnancy attitudes were no more likely than other respondents to use contraceptives either inconsistently or consistently, and no less likely to become pregnant. In contrast, the more positive respondents' attitudes toward contraceptives, the higher the likelihood that they used them, either inconsistently or consistently rather than not at all. Therefore, pregnancy interventions that focus on attitudes should prioritize attitudes toward contraception over those toward pregnancy.

The way programs focusing on attitudes toward pregnancy can make a difference is by helping adolescents who are ambivalent about pregnancy to form any opinion--regardless whether it is positive, negative or mainstream. Adolescents without an opinion about pregnancy were less likely than others to use contraceptives, and because contraceptive use among sexually experienced respondents is important in preventing pregnancy, getting ambivalent adolescents to form an opinion about pregnancy may be one step toward pregnancy prevention.

Even so, having an attitude toward pregnancy may help adolescents use contraceptives sometimes rather than never, but may not be a factor in getting them to use contraceptives consistently. Of the measures included in our study, risk status was the only factor that distinguished consistent and inconsistent contraceptive users. This cluster of interrelated factors likely reflect adolescents' strikingly different conceptions of the world and their place within it. Many adolescent pregnancy reduction interventions that have focused on widening adolescents' experience and understanding of life opportunities have shown success. (20) Additional efforts in this vein ought to supplement campaigns to change attitudes toward pregnancy per se, because even if the latter succeed in changing attitudes, our results indicate that they may fail to change behavior.

TABLE 1. Characteristics included in analyses of 15-19-year-old
females' contraceptive behavior and pregnancy risk, hypothesized
relationship between characteristic and outcomes, and measure used,
National Longitudinal Study of Adolescent Health

Characteristic                         Contra-    Preg-
                                       ception    nancy

Social and demographic
Age                                       +          +
Black                                     -          +
Hispanic                                  -          +
Maternal education                        +          -
Poor/low-income                           -          +

Family
Family structure                          +          -
Closeness with mother                     +          -

Individual
Religiosity                            Conflicting predictions
                                           and evidence in
                                              literature
AHPVT                                     +          -
AHPV[T.sup.2]/100                         -          -
Risk status                               -          +
Self-esteem                               +          0
Socially isolated                         -          0

Sexual
Length of sexual career                   -          +
Duration of interwave period              -          +
No.of sexual partners between waves       -          +
Prior pregnancy                           +          +
Attitudes toward contraception            +          na
Contraceptive use                         na         -
Knowledge about
  pregnancy avoidance                     +          -
Unfounded certainty                       -          +

Characteristic                         Measure

Social and demographic
Age                                    Age in years as of Wave 1, based
                                       on interview date and date of
                                       birth
Black                                  Self-reported at Wave 1
Hispanic                               Self-reported at Wave 1
Maternal education                     Respondent's report at Wave 1
Poor/low-income                        Respondent's report at Wave 1 of
                                       whether a parent or a parent's
                                       partner had received public
                                       assistance in the last year

Family
Family structure                       Family type (living situation)
                                       self-reported at Wave 1: two
                                       biological parents, at least one
                                       step parent, single parent and
                                       other
Closeness with mother                  Wave l response to the question
                                       How much do you think she
                                       [biological/adoptive/step/foster
                                       mother] cares about you?"
                                       (scale:0-4)

Individual
Religiosity                            Composite of responses to four
                                       items at Wave 1:frequency of
                                       religious service attendance,
                                       frequency of religious youth
                                       activity participation,
                                       importance of religion to self
                                       and frequency of praying
                                       (scale:0-1)
AHPVT                                  Abridged version of the Peabody
                                       Picture Vocabulary Test-Revised
AHPV[T.sup.2]/100                      Squared term of AHPV, to model
                                       curvilinear relationship
Risk status                            Composite typology of academic
                                       and behavioral orientation of
                                       adolescents
Self-esteem                            Composite of responses to nine
                                       belief statements at Wave 1:
                                       "You have a lot of energy," "You
                                       are well-coordinated," "You have
                                       a lot of good qualities," "You
                                       are physically fit," "You have a
                                       lot to be proud of," "You like
                                       yourself just the way you are,"
                                       "You feel like you are doing
                                       everything just about right,"
                                       "You feel socially accepted" and
                                       "You feel loved and wanted"
                                       (scale:0-4)
Socially isolated                      Respondent was considered
                                       socially isolated if fewer than
                                       three other respondents in
                                       school named her as friend

Sexual
Length of sexual career                Duration between sexual debut
                                       and Wave 2
Duration of interwave period           Duration of exposure to
                                       pregnancy risk between Wave 1
                                       and Wave 2
No.of sexual partners between waves    Self-reported at Wave 2
Prior pregnancy                        Self-reported at Wave 1
Attitudes toward contraception         Composite of responses to seven
                                       items about birth control at
                                       Wave 1: "too much of a hassle to
                                       use too expensive to buy,"
                                       "takes too much planning," "too
                                       hard to get a boy to use with
                                       you," "interferes with sexual
                                       enjoyment using it is morally
                                       wrong" and "if you used it, your
                                       friends might think that you
                                       were looking for sex"
                                       (scale:1-5)
Contraceptive use                      Consistency of use across all
                                       partnerships between waves
Knowledge about
  pregnancy avoidance                  Number of correct answers to
                                       nine true-or-false questions
                                       about proper condom usage,
                                       ovulation and pregnancy risk
                                       (scale:0-9)
Unfounded certainty                    Number of incorrect answers in
                                       the knowledge quiz about which
                                       the respondent was certain she
                                       was right (scale:0-9)

Notes: +=positive relationship. -=negative relationship. 0=no
relationship. na=not applicable. Wave 1 interviews were performed
between May and December 1995, and Wave 2 interviews were performed
between April and September 1996.

TABLE 2. Descriptive statistics for 15-19-year-old females, by their
attitude toward becoming pregnant and by whether they are sexually
experienced

Characteristic            Anti                Mainstream

                          No        Yes       No           Yes
                          (N=682)   (N=314)   (N=1,629)    (N=1,153)

Social and demographic
Age(mean)                  16.4      16.8      16.5         16.9
Race/ethnicity (%)
  White                    52.1      63.7      52.1         51.5
  Black                    16.0      14.7      18.1         27.0
  Hispanic                 15.4      13.7      21.1         15.0
  Other                    16.6       8.0       8.8          6.4
Maternal education
  (mean)                    6.0       6.1       5.7          5.4
Poor/low-income (%)         9.2       6.4      10.7         15.0

Family
Family structure (%)
  2 biological parents     63.8      54.5      58.6         38.4
  [greater tha or
    equal to] 1
    stepparent             14.8      20.4      14.6         21.9
  Single parent            17.9      21.0      22.8         29.0
  Other                     3.5       4.1       4.0         10.8
Closeness with mother       3.3       3.1       3.1          3.0

Individual
Religiosity (mean)          0.5       0.4       0.5          0.4
AHPVT(mean)               102.3     101.6     100.0         98.0
Risk status (%)
  Low                      54.8      30.6      45.1         19.3
  Middle                   29.0      33.1      35.5         31.6
  High                     16.1      36.3      19.3         49.1
Self-esteem (mean)          3.1       3.0       2.9          2.8
Socially isolated (%)      20.8      11.5      23.2         18.2

Sexual
Prior pregnancy
  at Wave 1(%)            na          6.5       na          15.8
Attitudes toward
  contraception (mean)      4.0       4.1       3.9          4.0
Knowledge about
  pregnancy avoidance
  (mean)                    5.4       6.3       5.4          6.2
Unfounded certainty
  (mean)                    0.7       0.7       0.7          0.8

Characteristic            Pro                     Ambivalent

                          No           Yes       No           Yes
                          (N=116)      (N=292)   (N=323)      (N=368)

Social and demographic
Age(mean)                 16.6         17.2      16.4         16.8
Race/ethnicity (%)
  White                   32.8         39.4      44.6         44.8
  Black                   29.3         41.1      17.3         32.1
  Hispanic                31.0         14.0      26.0         16.3
  Other                   ([dagger])    5.5      ([dagger])    6.8
Maternal education
  (mean)                   4.3          4.8       5.3          5.1
Poor/low-income (%)       19.0         27.4      14.6         20.1

Family
Family structure (%)
  2 biological parents    44.0         31.9      55.1         32.1
  [greater than or
    equal to] 1
    stepparent            17.2         16.4      15.2         27.2
  Single parent           31.9         34.6      25.4         29.9
  Other                   ([dagger])   17.1      ([dagger])   10.9
Closeness with mother      3.2          2.9       3.1          2.9

Individual
Religiosity (mean)         0.4          0.4       0.4          0.4
AHPVT(mean)               90.0         92.8      97.6         96.8
Risk status (%)
  Low                     37.9         14.7      35.0         14.1
  Middle                  23.3         27.1      35.9         29.9
  High                    38.8         58.2      29.1         56.0
Self-esteem (mean)         2.9          2.8       2.9          2.8
Socially isolated (%)     23.3         25.3      26.6         23.4

Sexual
Prior pregnancy
  at Wave 1(%)            na           43.0      na           21.2
Attitudes toward
  contraception (mean)     3.9          3.9       3.8          3.9
Knowledge about
  pregnancy avoidance
  (mean)                   4.9          6.0       5.4          6.3
Unfounded certainty
  (mean)                   1.3          1.2       0.6          0.6

Characteristic            Comparison
                          across attitude

                          No        Yes

Social and demographic
Age(mean)                 ns        **
Race/ethnicity (%)
  White                   **        **
  Black                   **        **
  Hispanic                **        ns
  Other                   **        ns
Maternal education
  (mean)                  **        **
Poor/low-income (%)       **        **

Family
Family structure (%)
  2 biological parents    **        **
  [greater than or
    equal to] 1
    stepparent            ns        **
  Single parent           **        **
  Other                   ns        **
Closeness with mother     **        **

Individual
Religiosity (mean)        **        ns
AHPVT(mean)               **        **
Risk status (%)
  Low                     **        **
  Middle                  **        **
  High                    **        **
Self-esteem (mean)        **        **
Socially isolated (%)     ns        **

Sexual
Prior pregnancy
  at Wave 1(%)            na        **
Attitudes toward
  contraception (mean)    **        **
Knowledge about
  pregnancy avoidance
  (mean)                            ns
Unfounded certainty
  (mean)                  **        **

* p<.05. ** p<.01. ([dagger]) Estimates not reported because of small
sample. Notes: ns=not significant. na=not applicable.

TABLE 3. Descriptive statistics for 15-19-year-old females,
by level of contraceptive use, according to selected
characteristics

Characteristic                    None      Inconsistent   Consistent
                                  (N=303)   (N=193)        (N=691)

All                               26.8      16.4           56.7

Social and demographic
Age (mean)                        16.7      16.9           16.7
Race/ethnicity (%)
  White                           70.8      72.5           70.9
  Black                           14.9      19.9           18.1
  Hispanic                         9.8       3.8 **         6.9
  Other                            4.5       3.8            4.2
Maternal education (mean)          4.7       5.1            5.0
Poor/low-income (%)               14.6       8.9           14.9

Family
Family structure (%)
  2 biological parents            47.2      45.6           48.8
  [greater than or equal to] 1
    stepparent                    21.8      26.0           19.1
  Single parent                   22.7      20.3           28.0
  Other                            8.3       8.1            4.2 *
Closeness with mother (mean)       3.0       3.0            3.1

Individual
Religiosity (mean)                 0.4       0.4            0.4
AHPVT(mean)                       85.6      88.1           88.2 *
Risk status (%)
  Low                             12.7      20.5 *         25.2 **
  Middle                          35.7      25.1           34.5
  High                            51.6      54.4           40.2 *
Self-esteem (mean)                 2.8       2.8            2.9 *
Socially isolated (%)             14.8      14.6           16.0

Sexual
Length of sexual
  career (mean)                    1.3       1.3            0.9 *
No. of sexual partners
  between waves (mean)             1.7       1.3 **         1.2 **
Prior pregnancy at
  Wave 1(%)                       11.7       9.6            6.3 *
Attitudes toward
  contraception (mean)             3.8       4.1 **         4.2 **
Knowledge about pregnancy
  avoidance (mean)                 6.1       6.4            6.1
Unfounded certainty (mean)         0.7       0.6            0.6
Attitudes toward pregnancy (%)
  Mainstream                      55.4      61.5           58.9
  Anti                            15.6      16.5           18.4
  Pro                             12.0      12.5           10.8
Ambivalent                        17.0       9.6 *         11.9

* Significantly different from nonusers at p<.05. ** Significantly
different from nonusers at p<.01. Note: Data are weighted.

TABLE 4. Odds ratios (and 95% confidence intervals) from multinomial
regression analyses predicting 15-19-year-olds females' contraceptive
use (versus nonuse), by contraceptive consistency, according to
selected characteristics

Characteristic                             Inconsistent

Social and demographic

Age
  15 (ref)                                 1.00
  16                                       1.26 (0.65-2.43)
  17                                       1.49 (0.69-3.23)
  18                                       0.96 (0.42-2.22)
Race/ethnicity
  White (ref)                              1.00
  Black                                    1.95 (0.90-4.23)
  Hispanic                                 0.75 (0.27-2.07)
  Other                                    1.39 (0.48-3.98)
Maternal education                         1.02 (0.91-1.15)
Poor/low-income                            0.66 (0.25-1.69)

Family
Family structure
  2 biological parents (ref)               1.00
  [greater than or equal to] 1
    stepparent                             1.74 (0.82-3.73)
  Single parent                            1.08 (0.57-2.06)
  Other                                    1.16 (0.21-6.36)
Closeness with mother                      0.86 (0.58-1.25)

Individual
Religiosity                                0.78 (0.26-2.34)
AHPVT                                      1.31 (1.02-1.68) *
AHPV[T.sup.2]/100                          0.99 (0.99-1.00) *
Risk status
  Middle (ref)                             1.00
  Low                                      2.04 (1.03-4.05) *
  High                                     1.29 (0.69-2.44)
Self-esteem                                1.00 (0.62-1.64)
Socially isolated                          1.38 (0.60-3.16)

Sexual
Length of sexual career                    1.04 (0.87-1.26)
Duration of interwave period               0.94 (0.83-1.06)
No. of sexual partners between waves       0.40 (0.27-0.61) **
Prior pregnancy at Wave 1                  1.05 (0.44-2.48)
Attitudes toward contraception             1.57 (1.06-2.30) *
Knowledge about pregnancy avoidance        1.04 (0.88-1.23)
Unfounded certainty                        0.84 (0.64-1.10)
Attitudes toward pregnancy
  Mainstream (ref)                         1.00
  Anti                                     0.86 (0.39-1.92)
  Pro                                      0.89 (0.38-2.10)
  Ambivalent                               0.37 (0.18-0.75) **

Characteristic                             Consistent

Social and demographic
Age
  15 (ref)                                 1.00
  16                                       1.23 (0.75-2.02)
  17                                       1.06 (0.60-1.86)
  18                                       0.53 (0.26-1.05)
Race/ethnicity
  White (ref)                              1.00
  Black                                    1.37 (0.63-2.95)
  Hispanic                                 1.60 (0.80-3.21)
  Other                                    1.62 (0.72-3.65)
Maternal education                         0.99 (0.88-1.11)
Poor/low-income                            1.31 (0.67-2.55)

Family
Family structure
  2 biological parents (ref)               1.00
  [greater than or equal to] 1
    stepparent                             1.27 (0.70-2.29)
  Single parent                            1.31 (0.76-2.25)
  Other                                    0.50 (0.14-1.84)
Closeness with mother                      0.87 (0.64-1.18)

Individual
Religiosity                                0.78 (0.35-1.77)
AHPVT                                      1.24 (1.06-1.45) **
AHPV[T.sup.2]/100                          0.99 (0.99-1.00) *
Risk status
  Middle (ref)                             1.00
  Low                                      1.77 (1.05-2.98) *
  High                                     0.77 (0.47-1.26)
Self-esteem                                1.21 (0.80-1.84)
Socially isolated                          1.87 (0.98-3.55)

Sexual
Length of sexual career                    0.96 (0.86-1.07)
Duration of interwave period               0.98 (0.87-1.11)
No. of sexual partners between waves       0.34 (0.24-0.49) **
Prior pregnancy at Wave 1                  0.96 (0.42-2.19)
Attitudes toward contraception             2.07 (1.54-2.79) **
Knowledge about pregnancy avoidance        0.99 (0.89-1.10)
Unfounded certainty                        0.87 (0.72-1.05)
Attitudes toward pregnancy
  Mainstream (ref)                         1.00
  Anti                                     0.85 (0.51-1.41)
  Pro                                      0.80 (0.42-1.54)
  Ambivalent                               0.50 (0.28-0.88) *

* p<.05. ** p<.01. Note: ref=reference group.

TABLE 5. Descriptive statistics for 15-19-year-old females,
by whether they had a pregnancy between survey waves

Characteristic                            No           Yes
                                          (N=1,187)    (N=228)
Social and demographic
Age (mean)                                16.7         16.9
Race/ethnicity (%)
  White                                   71.2         57.2 **
  Black                                   17.5         25.2 *
  Hispanic                                 7.2         13.8 **
  Other                                    4.2          3.8
Maternal education (mean)                  4.9          4.4 *
Poor/low-income (%)                       13.8         19.6

Family
Family structure (%)
  2 biological parents                    47.8         30.0 **
  [greater than or equal to] 1
    stepparent                            21.0         21.4
  Single parent                           25.3         32.9
  Other                                    5.9         15.7 **
Closeness with mother (mean)               3.0          2.9 *

Individual
Religiosity (mean)                         0.4          0.4
AHPVT(mean)                               87.5         84.5 **
Risk status (%)
  Low                                     21.1         16.3
  Middle                                  33.3         28.9
  High                                    45.6         54.8 *
Self-esteem (mean)                         2.8          2.8
Socially isolated (%)                     15.5         18.0

Sexual
Length of sexual career (mean)             1.1          1.7 **
Prior pregnancy at Wave 1 (%)              8.3         23.3 **
Contraceptive use (%)
  None                                    26.8         72.9 **
  Inconsistent                            16.5         12.1
  Consistent                              56.7         15.1 **
Knowledge about pregnancy
  avoidance (mean)                         6.2          6.3
Unfounded certainty (mean)                 0.6          0.9 *
Attitudes toward pregnancy (%)
  Mainstream                              58.4         55.4
  Anti                                    17.3         10.9
  Pro                                     11.4         18.1
  Ambivalent                              12.9         15.6

* p<.05. ** p<.01.

TABLE 6. Odds ratios (and 95% confidence intervals) from
logistic regression analysis predicting 15-19-year-old
females'risk of pregnancy, by selected characteristics

Characteristic                            Odds ratio

Social and demographic
Age
  15 (ref)                                 1.00
  16                                       0.91 (0.45-1.82)
  17                                       0.88 (0.49-1.57)
  18                                       0.97 (0.40-2.39)
Race/ethnicity
  White (ref)                              1.00
  Black                                    1.38 (0.86-2.23)
  Hispanic                                 2.42 (1.30-4.50) **
  Other                                    1.26 (0.54-2.96)
Maternal education                         0.96 (0.86-1.08)
Poor/low-income                            1.21 (0.67-2.19)

Family
Family structure
  2 biological parents (ref)               1.00
  [greater than or equal to] 1 stepparent  1.57 (0.91-2.73)
  Single parent                            2.05 (1.19-3.51) *
  Other                                    1.86 (0.66-5.26)
Closeness with mother                      0.84 (0.67-1.05)

Individual
Religiosity                                1.03 (0.45-2.36)
AHPVT                                      1.34 (1.07-1.68) *
AHPV[T.sup.2]/100                          0.99 (0.99-1.00) *
Risk status
  Middle (ref)                             1.00
  Low                                      1.43 (0.66-3.10)
  High                                     1.13 (0.72-1.78)
Self-esteem                                1.40 (0.82-2.39)
Socially isolated                          1.00 (0.54-1.86)

Sexual
Sexual career length                       1.08 (0.96-1.21)
Duration of interwave period               1.08 (0.95-1.23)
Prior pregnancy at Wave 1                  1.98 (1.06-3.71) *
Contraceptive use
  Consistent (ref)                         1.00
  Inconsistent                             2.76 (1.46-5.22) **
  None                                    11.39 (7.25-17.9) **
Knowledge about pregnancy avoidance        1.08 (0.93-1.25)
Unfounded certainty                        1.15 (0.95-1.40)
Attitudes toward pregnancy
  Mainstream (ref)                         1.00
  Anti                                     0.77 (0.38-1.56)
  Pro                                      0.96 (0.49-1.88)
  Ambivalent                               0.80 (0.45-1.45)

* p<.05. ** p<.01. Note: ref=reference group.

Acknowledgments

The authors thank Henning, Hillmann for his helpful comments. This research uses data from Add Health, a program project designed by J. Richard Udry, Peter S. Bearman and Kathleen Mullah Harris, and funded by a grant PO1-HD31921 from the National Institute of Child Health and Human Development, with cooperative funding from 17 other agencies. Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Persons interested in obtaining data files from Add Health should contact Add Health, Carolina Population Center, 123 W. Franklin Street, Chapel Hill, NC 27516-2524, (<http://www.cpc.unc.edu/addhealth/contract.html>).

* Two studies found an association between positive or ambivalent attitudes toward childbearing and subsequent childbearing among samples of clinic clients presenting for pregnancy tests (sources: Zabin LS, Hirsch MB and Boscia JA, Differential characteristics of adolescent pregnancy test patients: abortion, childbearing and negative test groups, Journal of Adolescent Health, 1990,11 (2):107-113;and Zabin LS, Sedivy V and Emerson MR, Subsequent risk of childbearing among adolescents with negative pregnancy test, Family Planning Perspectives, 1994, 26(5):212-217).

(#) A detailed methodological supplement reporting sensitivity tests for results based on different conceptualizations is available from the corresponding author.

** It was possible that excluding teenagers who became pregnant between waves would select respondents more likely to have positive attitudes toward pregnancy or more likely to be inconsistent users or nonusers of contraception. This was not the case. Attitudes toward pregnancy do not predict pregnancy in either group; analyses supporting this are available from the corresponding author. The small number of respondents who became pregnant prohibited a separate analysis of whether their attitudes toward pregnancy predicted contraceptive use. Many respondents who became pregnant reported that they had used contraceptives.

(##) Here, a number of small changes are introduced. Specifically, contraceptive consistency, as determined in the previous model, is included among the sexual characteristics; attitude toward contraception is excluded because of its redundancy with the consistency of use measure. To ensure the correct temporal order, we excluded the number of partners between waves because for respondents who became pregnant, it may have included relationships following the pregnancy.

([dagger]) Previous research argues that the absence of a relationship between attitudes and behavior in social science research is due to an inexact correspondence between the measured attitudes and behavior in the action of interest, the target of that action or both (sources: Ajzen I and Fishbein M, Attitudinal and normative variables as predictors of specific behaviors, Journal of Personality and Social Psychology, 1973,27(1):41-57; and Ajzen I and Fishbein M, Attitude-behavior relations: a theoretical analysis and review of empirical research, Psychology Bulletin, 1977,84(5):888-918). In this study, the measured attitudes referred precisely to the action of interest; thus, the target is not relevant. However, the absence of a relationship between pregnancy attitudes and pregnancy risk may be in part the consequence of forced sex or rape. If respondents were raped, their attitudes toward pregnancy are not relevant for their risk of pregnancy. Add Health did not collect data that would allow us to assess this possibility.

REFERENCES

(1.) Kirby D, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001.

(2.) Jaccard J, Dodge T and Dittus P, Do adolescents want to avoid pregnancy? attitudes towards pregnancy as predictors of pregnancy, Journal of Adolescent Health, 2003, 33(2):79-83

(3.) Witte K, Preventing teen pregnancy through persuasive communications: realities, myths, and the hard-fact truths, Journal of Community Health, 1997, 22(2):137-154; and Stevens-Simon C et al., Why pregnant adolescents say they did not use contraceptives prior to conception, Journal of Adolescent Health, 1996, 19(1):48-53.

(4.) Kirby D, No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 1997; and Stevens-Simon C et al., 1996, op. cit. (see reference 3)

(5.) Kirby D, 2001, op. cit. (see reference 1).

(6.) Ibid.

(7.) Ibid.

(8.) Bearman PS and Bruckner H. Power in Numbers: Peer Effects on Adolescent Girls' Sexual Debut and Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 1999; Bruckner H and Bearman PS, Dating behavior and sexual activity among young adolescents, in: William A, Brown S and Flanagan C, eds., Fourteen and Younger: The Sexual Behavior of Young Adolescents, Washington, DC: National Campaign to Prevent Teen Pregnancy, 2003: Kirby D, 1997, op. cit. (see reference 4); and Kirby D, 2001, op cit (see reference 1).

(9.) Jaccard J, Dodge T and Dittus P, 2003, op. cir. (see reference 2).

(10.) Sable MR, Pregnancy intentions may not be a useful measure for research on maternal and child health outcomes, Family Planning Perspectives, 1999, 31(5):249-250; Zabin LS, Ambivalent feelings about parenthood may lead to inconsistent contraceptive use-and pregnancy, Family Planning Perspectives, 1999, 31(5):250-251; and Trussell J, Vaughan B and Stanford J, Are all contraceptive failures unintended pregnancies? evidence from the 1995 National Survey of Family Growth, Family Planning Perspectives, 1999, 319(5):246-247.

(11.) Zabin LS, Astone NM and Emerson MR, Do adolescents want babies? the relationship between attitudes and behavior, Journal of Research on Adolescence, 1993, 3(1):67-86.

(12.) Bachrach CA and Newcomer S, Intended pregnancies and unintended pregnancies: distinct categories or opposite ends of a continuum? Family Planning Perspectives, 1999, 31(5):251-252.

(13.) Bearman PS, Jones J and Udry RJ, The National Longitudinal Study of Adolescent Health: Research Design, Chapel Hill, NC: Carolina Population Center, University of North Carolina, 1997.

(14.) Bearman PS and Bruckner H, 1999, op. cit. (see reference 8).

(15.) Carolina Population Center, Strategies to perform a design-based analysis using the Add Health data, 1999, <http://www.cpc.unc.edu/ projects/addhealth/strategies.html>, accessed Aug. 21, 2004.

(16.) Halpern CT et al., Smart teens don't have sex (or kiss much either), Journal of Adolescent Health, 2000, 26(3):213-225

(17.) Jaccard J, Dodge T and Dittus P, 2003, op. cit. (see reference 2).

(18.) Ibid.

(19.) Mensch B and Kandel D, Drug use as a risk factor for premarital teen pregnancy and abortion in a national sample of young white women, Demography, 1992, 29(3):409-429.

(20.) Card JJ, Teen pregnancy prevention: do any programs work? Annual Review of Public Health, 1999, 20(1):257-285; Kirby D, 1997, op. cit (see reference 4); and Kirby D, 2001, op. cir. (see reference 1).

Hannah Bruckner is assistant professor, Department of Sociology, Yale University, New Haven, CT. Anne Martin is postdoctoral fellow, National Center for Children and Families, Teachers College; and Peter S. Bearman is professor, Department of Sociology-both with Columbia University, New York.

Author contact: [e-mail]