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Organized responses to adolescent sexual and reproductive behavior.

Parents and other adults have long tried to influence and control the sexual behavior of adolescents, especially young women, through admonitions, curfews, limitations on dating and forced marriage. The last two decades have seen the proliferation of organized interventions that parallel and supplement individual efforts to reduce teenage sexual activity and its negative consequences. Many of these interventions have focused either on trying to persuade adolescents, particularly young women, to abstain from sexual activity or on providing remedial services to pregnant teenagers and adolescent parents. Both of these approaches have instinctual appeal, but neither has been effective enough or perhaps intensive enough to have a major impact. On the other hand, there is evidence that some programs have succeeded in reducing levels of unprotected sexual behavior and pregnancy among young people who participate in them. The most effective programs typically combine innovative instructional techniques with informati on about methods to prevent pregnancy and STD transmission; some also facilitate adolescents' access to contraceptive services. Such programs are still relatively rare, however, and have yet to be implemented on a national scale.

Different Approaches

Programs designed to provide special services to pregnant teenagers who decide to give birth are perhaps the oldest form of organized intervention. Originally, these programs primarily entailed providing residential care for pregnant young women outside their home communities until they gave birth and, usually, relinquished their babies for adoption. As it has become the norm for pregnant adolescents to continue to live at home, attend school and keep their babies, these programs have evolved. They now concentrate on providing both necessary medical services, to ensure that young women receive adequate prenatal care so they will have healthy birth outcomes, and support services, to help adolescent mothers stay in school and learn skills they need as parents. Not all pregnant adolescents have access to coordinated services and support, however, because these programs are quite intensive and therefore costly.

Meanwhile, many family planning clinics and almost all school systems now offer sex education aimed at increasing young people's knowledge about reproduction. Some of these programs also provide information about contraception and STD transmission, and include lessons in communication skills. Programs associated with family planning clinics facilitate teenagers' access to medical contraceptive services, and a few schools have opened clinics that provide contraceptive and STD services or have implemented programs to make condoms available to students.

During the last decade, policies and programs designed to encourage abstinence among unmarried teenagers have become increasingly popular. Some of these programs have attempted to accomplish this objective by giving young people encouragement, offering moral support and teaching interpersonal skills to resist pressures to become sexually active. (236) Others have sought to convince teenagers that sex before marriage is immoral and have emphasized the negative consequences of sexual intercourse, while occasionally withholding or distorting information about the availability and effectiveness of contraceptives. (237)

On a broader scale, community and service organizations have implemented interventions aimed at increasing the life options of disadvantaged young people through, for example, role models and mentoring, community service projects, job training and activities aimed at reducing risky behaviors. Such interventions are expected indirectly to reduce levels of unintended teenage pregnancy and childbearing and sexually transmitted infections, in the belief that teenagers who are more positive about their futures are less likely to participate in risk-taking behaviors, including risky sexual practices.

Several model communitywide programs for high-risk, inner-city populations have linked substance abuse prevention with delinquency prevention, pregnancy prevention or educational achievement. (238)

Difficulty in Evaluating Programs

The numerous programs designed to address teenage sexual and reproductive behavior differ widely in content, type of intervention, group served, and breadth and comprehensiveness of their focus. Yet, very few of them have been evaluated, and even fewer have been evaluated adequately.

* Many programs do not have sufficient funding to support both program activities and evaluation, or have not been in existence long enough to be evaluated.

* It is frequently difficult to get support from communities and schools for evaluations that include asking teenagers about sexual behavior.

* Some programs are run by individuals who are confident about the impact of their activities and do not see the need for formal evaluation.

The focus here is primarily on programs that have been evaluated in a formal way; in some instances, new or promising program approaches for which no formal evaluations are available are also mentioned. For the most part, evaluations of pregnancy and STD prevention programs have attempted to measure change in adolescents' knowledge and attitudes regarding sexuality and reproduction, as well as change in their behavior--specifically, whether they delay the initiation of sexual intercourse and increase contraceptive use when they do have sex. Ultimately, programs that succeed in achieving these goals should lead to reduced levels of pregnancies, births and STDs among teenagers. This leap in expectations is not always borne out by those programs with adequate evaluations, however.

* In some cases, expectations may be too high. Education alone is not sufficient to change behavior deeply ingrained by one's cultural upbringing, the pressure of one's peers and the media.

* Even programs that have been successful in delaying the initiation of sexual activity and increasing reported contraceptive use among participants have not shown significant declines in teenage pregnancy rates.

* Intervention programs and their evaluations usually focus on short-term behavior changes. Thus, short delays in the initiation of intercourse or greater contraceptive use following an intervention that is not sustained in the long run may not be sufficient to significantly lower teenage pregnancy rates, given a typical span of eight years between the initiation of intercourse and marriage.

There are a number of problems associated with evaluation of pregnancy and STD prevention programs. Foremost among these are difficulties in obtaining valid outcome measures and in designing evaluations that can actually assess program effectiveness.

In terms of outcome, most evaluations rely on reports from teenagers themselves regarding levels of sexual activity, contraceptive use, pregnancy, abortion and STDs--all of which are difficult to measure, whether a program is in place or not. Alternatively, some evaluations use external data, countywide birthrates and abortion rates or estimated schoolwide pregnancy rates to measure program effectiveness. Schoolwide rates have been shown to fluctuate widely from year to year, (239) however, and countywide rates may be based on a pool of adolescents that is much larger than the group of teenagers participating in the program, which would dilute the effect of a program operating in only one school. In addition, because abortion data are usually reported according to the county in which the procedure occurs, it is difficult to calculate adolescent abortion rates according to county of residence. (230)

In terms of evaluation design, most studies attempt to compare program participants with a control group, such as students from other classrooms, other schools or other counties. Such comparisons, however, are fraught with difficulties.

* Control students usually receive some sort of sex education.

* Community messages about sexual behavior may reach both participants and controls.

* Media events or heightened public discussion of AIDS may have an unmeasured impact on the behavior being evaluated.

* Unless participants are randomly assigned to program and control groups, teenagers opting for the program may be self-selected or selected by their parents or program staff because they have special needs. Even if the program has an effect, members of the control group may do well because they were better off to begin with.

Despite these limitations, program evaluations can be extremely useful in gauging the effectiveness of different program approaches. Those that have been done carefully provide insight into what strategies work well with adolescents.

Pregnancy and STD Prevention Programs

Increasing Knowledge and Skills. Perhaps the most common intervention, and the one that reaches the most young people, is classroom instruction in schools that is designed to increase teenagers' knowledge about sexuality.

* In the late 1980s, 76% of young women aged 15--19 (241) and 75% of young men in that age-group (242) reported that before age 18, they had received some formal instruction related to methods of birth control.

* Some 79% of the young women (and 81% of the young men) reported receiving formal instruction about STDs. (243)

* Currently, 46 states and the District of Columbia mandate or recommend that schools provide sexuality education, while all 50 states and the District of Columbia mandate or recommend that schools provide AIDS education. (244) States are more likely, however, to require (as opposed to recommend) AIDS education than sex education. (245) But AIDS instruction is often less than candid about sexual transmission.

While traditional sex education has been successful in achieving the limited goal of increasing knowledge, (246) students do not appear to change their sexual behavior or increase their use of contraceptives unless the program provides specific information on how to resist sexual pressures and how to prevent pregnancy and disease. (247)

* When sexuality education includes explicit discussion of contraceptive methods and prevention of STDs, it increases students' knowledge of the effectiveness of different methods for preventing pregnancy and disease transmission, and sometimes raises contraceptive use among program participants.

* High school students who have received AIDS education are more knowledgeable about HIV transmission than are students who have not received such education, and in some cases are significantly less likely to participate in risky sexual behaviors? (248)

Curricula have been designed that combine sexuality education with interactive instruction emphasizing values and norms for responsible behavior and decision making so that students learn the communication skills needed to say "no" or "not yet" to sexual intercourse or unprotected sex. Some of the schoolbased programs that use this approach have had positive effects on participants' behavior. (249)

* Students delay the initiation of sexual intercourse. One study, for example, estimated that participants postponed sexual activity for seven months. (250)

* Participants become more likely to use condoms and other contraceptives. Three programs that were evaluated reported that 13-50% more participants than controls use contraceptives. (251)

* Higher proportions of participants than of controls were in monogamous relationships, and smaller proportions had high-risk partners, after the intervention. (252)

Not all school-based interventions report significant changes, however. To better understand why some programs are successful, while others are not, a panel of experts reviewed all published evaluations of school-based pregnancy and STD prevention programs. The results of this review suggest that characteristics of a program's curriculum and instructional techniques may determine its effectiveness. Successful interventions share a number of characteristics, including the following:

(a) theoretical grounding in social learning or social influence theories,

(b) a narrow focus on reducing specific sexual risk-taking behaviors,

(c) experiential activities to convey the information on the risks of unprotected sex and how to avoid those risks and to personalize that information,

(d) instruction on social influences and pressures,

(e) reinforcement of individual values and group norms against unprotected sex that are age and experience appropriate, and

(f) activities to increase relevant skills and confidence in those skills."

Service organizations and community agencies--such as Girls, Inc.; Boys Clubs; the Association of Junior Leagues; the American Red Cross; the Young Women's Christian Association; and churches--frequently offer after-school and summer programs that focus on increasing the life options of disadvantaged youth and on preventing risk-taking behaviors among teenagers; many include sexuality education and sexual decision making. These programs, particularly the components focused on pregnancy prevention, have had mixed results.

* One model that includes weekly support group meetings and involvement in community service activities has been implemented in several cities throughout the United States and has documented reductions in school dropout rates and pregnancy rates among enrolled teenagers. (254)

* Other service organization programs have not been evaluated adequately, although one reports differences between participants and controls that suggest that the program is effective in reducing pregnancy rates. (255)

* Recruitment into extracurricular prevention programs is often difficult, especially for those program components in which both the teenager and a parent are expected to participate. (256)

The value of these programs should not be discounted, however. By providing alternative role models for disadvantaged youth and involving them in community service projects, these programs can enhance adolescents' self-esteem and sense of the future, and may indirectly have some influence in lowering levels of teenage pregnancies and births.

Combining Education and Access to Contraceptive Services. Programs that combine sexuality education, counseling and small group discussions with easy access to medical family planning services have been successful in delaying the onset of sexual activity among participants, increasing contraceptive use rates among those who are sexually active and reducing pregnancy rates. (257)

It would appear that the success of this intensive approach depends, in part, on the rapport and trust that program staff, which often includes social workers and other professionals from external agencies, are able to establish with participants. Thus far, these intensive interventions have involved mainly high risk youth in inner-city schools. (258)

Over the last decade, school-based and school-linked health clinics have become increasingly common. Over 400 such clinics are now in existence. (259)

* Many of these clinics provide sexuality education and reproductive health care and counseling, but only 33% dispense condoms or other methods of birth control. (260)

* Some studies of school-based clinics that provide comprehensive contraceptive services show significant declines in pregnancy rates and birthrates among students in those schools, but others demonstrate no significant reductions in these rates. (261)

Growing national concern over the threat of AIDS has led to the establishment of condom distribution programs in some public schools. Although such programs are now favored by 60% of adults, (262) only 8% of the nation's high school and middle school students live in districts where condom distribution programs have been approved? (263) To date, none of these programs has been evaluated to assess the impact on condom use or levels of STD transmission.

Organized family planning clinics are an important resource for teenagers who are sexually experienced and need medical contraceptive services.

* Nearly 30% of women who obtain services from family planning clinics are under age 20. (264)

* Teenagers often prefer to obtain services from clinics rather than from private physicians because of lower fees and a belief that clinics offer greater confidentiality. (265)

* Teenagers attending family planning clinics with special protocols for adolescents have relatively few problems with contraceptive use, high continuation rates and low pregnancy rates? (266)

Comprehensive, communitywide approaches that encourage abstinence by teaching communication and life skills, provide accurate information on contraceptive methods and STD prevention, and facilitate access to contraceptives have been implemented in a limited number of places. In some cases, such programs have been successful in reducing birthrates among adolescents. They are most likely to be successful if they have broad-based community support from parents, the schools, churches, community leaders and even the media. In one evaluated program, for example, teachers and school administrators attended graduate-level sex education courses at a local college, and clergy, community leaders and parents were recruited to attend comprehensive, one-day seminars. Schools were then better equipped to integrate family life education into the curriculum at all grade levels (K-12), while lay people and community leaders were trained to be better parents and role models for teenagers. (267) Staff at the schools also arrang ed for sexually experienced students to have access to contraceptive services in the community and distributed condoms on-site. However, a reevaluation of this program found that while community teenage birthrates declined significantly during the program's first three years, they returned to preintervention levels once the program lost its momentum and school personnel were restrained in their efforts to facilitate contraceptive access. (268)

Many communities around the country have formed coalitions aimed at developing strategies to reduce teenagers' levels of unintended pregnancies and likelihood of engaging in risk-taking behaviors. These coalitions have obtained commitments from community officials and funding agencies and have begun to initiate a variety of activities, including media campaigns, school programs, outreach activities, referrals and case coordination. Originally, evaluation was not included as a component of any of these efforts, but several communities have subsequently used available funds to develop comprehensive approaches, encompassing systematic evaluations of both the processes involved and the outcomes measured. None of these evaluations has yet been completed or published, however. (269)

Abstinence as the Only Choice. Some programs take a very narrow approach to adolescent sexuality: They promote abstinence until marriage as the only moral and healthy choice for teenagers and explicitly refuse to provide information about contraceptive methods or STD prevention.

* In the short run, students who go through such a program report more favorable opinions regarding abstinence than do those who have not received such instruction. (270)

* No scientific evaluations have demonstrated that such curricula actually raise the likelihood that students will abstain from sexual activity.

* Once they become sexually active, teenagers who have participated in one of these programs maybe at higher risk for pregnancy and STDs because they have less information, as well as less-accurate information, about prevention strategies, and may even be misinformed about the use and effectiveness of specific methods. (271)

Sexual Activity Not Encouraged. An important finding of many evaluations of primary prevention efforts is that programs designed to increase teenagers' knowledge about sexuality issues, including pregnancy and STD prevention, and to improve access to medical contraceptive services do not encourage participants to engage in sexual activity earlier or more frequently than their peers who are not involved in such programs; nor do they result in higher pregnancy rates or birthrates in the communities where they are located. (272)

This finding is valid even though several national surveys of young people conducted in the 1970s and early 1980s produced inconsistent conclusions regarding the relationship between sex education and the initiation of sexual activity.

* Two studies suggested that young people aged 15-17, but not 18-19-year-olds, are more likely to initiate intercourse if they have taken a sex education course. (273)

* Other national studies have found either that there is no relationship between sex education and the initiation of sexual activity, or that teenagers who receive sex education are less likely than others to be sexually active. (274)

Among all of these studies, data on the content and comprehensiveness of the sex education received are lacking. Thus, conclusions regarding the association between sex education and sexual activity based on past national surveys are less reliable than are conclusions based on studies that evaluate the effects of specific educational curricula using quasi-experimental procedures to assign students into intervention and control groups.

In fact, while some of the evaluated programs show no significant impact on adolescent sexual activity, others show that participation lowers teenagers' likelihood of initiating sexual activity.

* For example, compared with controls, 6-38% fewer teenagers who participated in three evaluated programs were sexually active at the time of the evaluation follow-up. (275)

* Typically, the programs documenting the largest differences between participants and controls in terms of sexual activity and contraceptive use are the most intensive, ongoing programs, combining several approaches in an attempt to reach high-risk youth.

Programs for Pregnant Teenagers and Adolescent Parents

Many programs focus on improving teenagers' access to clinical reproductive health services, whether in school-based, school-linked or family planning clinics. These programs facilitate early detection of pregnancy among adolescents, and allow young women to consider all possible options for resolving their pregnancy, including adoption and abortion.

So far, there are few data on the effects of programs that focus primarily on providing teenagers with information about adoption and encouraging this option, although several studies have compared either the prior characteristics or the later outcomes of teenagers who choose to relinquish through adoption a baby whose birth was unintended with those of adolescent parents who choose to raise the child themselves. (276) As noted earlier, however, few teenage mothers place their infants for adoption, and the proportion who do so has been declining. (277)

Federal law stipulates that pregnant students may not be barred from attending schools that receive public funds. (278) Intensive, school-based programs have been implemented to deal with a variety of needs unique to the relatively small group of teenagers who become parents. These programs include services that help teenagers finish high school (especially child care) and facilitate career planning, and have resulted in more teenagers' remaining in school after the birth of their child. (279)

* In some cases, these programs are integrated with regular school courses, and the young women are offered special courses stressing the importance of prenatal care and teaching infant care and skills needed for parenthood. Day care may be provided, and caseworkers may meet with pregnant teenagers to assess and coordinate other services they may need, such as prenatal care, welfare benefits, counseling and child care.

* In other cases, these programs are separate from the regular school program, and participants attend all courses apart from other students during their pregnancies and usually for a short time postpartum.

Private and publicly funded group homes and residential care centers are available in some communities and large cities for a small number of young women who can no longer remain at home. These homes may offer pregnant teenagers and adolescent parents a place to live where they can receive social and financial support, child care and counseling while they complete high school or get job training.

The most intensive programs use a case management approach to facilitate medical and social support for teenagers during pregnancy and after the birth of their child. These programs have sometimes resulted in increased levels of prenatal care among teenagers, a decline in the number of low-birth-weight infants, fewer repeat pregnancies among teenage mothers, higher graduation rates and greater economic self-sufficiency. (280) Some of these positive effects last only a short time, however. (281) In the longer run, differences between program participants and controls in terms of repeat pregnancies and graduation rates diminish, which indicates that these programs are most effective in crisis management and that strategies to deal with the long-term consequences of teenage parenthood are still needed. Community-based or clinic-based programs that encourage adolescent mothers to use contraceptives and to refrain from having further nonmarital births in their teenage years also lead to declines in repeat pregnan cies, at least in the short term. (282)

A policy of offering increased welfare payments to teenage parents as an incentive to remain in school, and of reducing welfare payments for those who drop out, has been found to increase school attendance by teenage parents. The results are preliminary, however, and it is not clear whether such a policy causes graduation rates to go up. (293)

It is relatively easy to increase teenagers' knowledge about sexuality, but getting them to change their behavior requires more intensive interventions. The intensity of the interventions required depends on where along the reproductive spectrum teenagers are. For example, all teenagers need information and interpersonal skills; sexually active teenagers need access to contraceptive services. Adolescents who become parents require much more intensive interventions--ones that go far beyond even the most comprehensive sex education program and that include programs to help them stay in school, child care services and instruction in parenthood skills. Many also need programs to help young parents become economically self-sufficient, welfare and Medicaid, and child support payments from the baby's father if the parents are not married or living together (Figure 54, pages 70-71).

(236.) See, e.g., Howard and McCabe, 1992.

(237.) Gambrell and Kantor, 1992/1993.

(238.) Dryfoos, 1990.

(239.) Kirby et al., 1993, p. 14.

(240.) Henshaw and Van Vort, 1990, p. 105.

(241.) AGI, 1993b.

(242.) Ku, Sonenstein and Pleck, 1992, Table 1, p. 102.

(243.) AGI, 1993b; Ku, Sonenstein and Pleck, 1992, Table 1, p. 102.

(244.) Britton, De Mauro and Gambrell, 1992/1993, p. 2; Haffner, 1992, p. 1.

(245.) Kenney, Guardado and Brown, 1989, p. 56.

(246.) Kirby, 1984, pp. 385-407.

(247.) Kirby 1984, pp. 385-407; Kirby et al., 1994; Stout and Rivara, 1989.

(248.) Anderson et al., 1990, p. 252; Ku, Sonenstein and Pleck, 1992, p. 100; Walter and Vaughn, 1993, pp. 725, 728.

(249.) Barth et al., 1992; Elsen and Zellman, 1992; Howard and McCabe, 1992; Walter and Vaughn, 1993, p. 725.

(250.) Zabin, 1992, p. 170.

(251.) Barth et al., 1992, p. 70; Howard and McCabe, 1990, p. 24; Zabin, 1992, p. 173.

(252.) See, e.g., Walter and Vaughn, 1993, Figure 54, p. 728.

(253.) Kirby et al., 1994.

(254.) Philliber and Allen, 1992.

(255.) Nicholson and Postrado, 1992.

(256.) Brindis, 1991; Nicholson and Postrado, 1992, pp. 124-125.

(257.) Zabin et al., 1986.

(258.) Zabin et al,, 1986, Figure 1, p. 122; Zabin, 1992, p. 158.

(259.) McKinney and Peak, 1994.

(260.) McKinney and Peak, 1994.

(261.) Dryfoos, 1988, p. 196; Edwards et al., 1980, p. 6; Kirby et al., 1993, p. 12; Kirby and Waszak, 1992, p. 211; Zabin, 1992.

(262.) Elam, Rose and Gallup, 1993, pp. 15-16.

(263.) Leitman, Kramer and Taylor, 1993, p. 4.

(264.) CDC, 1994, pp. 31-34.

(265.) Chamie et al., 1982, p. 137.

(266.) Ralph and Edgington, 1983, p. 158; Winter and Breckenmaker, 1991, p. 24.

(267.) Vincent, Clearie and Schluchter, 1987.

(268.) U.S. Congress, Office of Technology Assessment, 1991, pp. 368-371.

(269.) Brindis, 1991, ch. 3, pp. 47-76.

(270.) Olsen et al., 1991, pp. 639-640.

(271.) Trudell and Whatley, 1991, p. 125.

(272.) Berger et al., 1987, p. 436; Dryfoos, 1988, pp. 193-196; Forrest, Hermalin and Henshaw, 1981, pp. 112-113; Kirby et al., 1994; Kirby and Waszak, 1992, p. 211.

(273.) Marsiglio and Mott, 1986, p. 151; Zelnik and Kim, 1982, p. 123.

(274.) Dawson, 1986, p. 162; Furstenberg, Moore and Peterson, 1985, p. 1331; Ku, Sonenstein and Pleck, 1992, pp. 102-103.

(275.) Barth et al., 1992, p. 69; Howard and McCabe, 1992, p. 102; Zabin et al., 1986, p. 122.

(276.) Bachrach, Stolley and London, 1992; Kalmuss, Namerow and Cushman, 1992; McLaughlin, Manninen and Winges, 1988.

(277.) Bachrach, Stolley and London, 1992, p. 29, Table 1.

(278.) Title IX of the Educational Amendments of 1972.

(279.) Wallace, Weeks and Medina, 1982; Warrick et al., 1993; Zellman, 1982.

(280.) Korenbrot et al., 1989, p. 97; Polit, 1989, p. 164; Rabin, Seltzer and Pollack, 1992, p.66.

(281.) Hanson, 1992; Polit, 1989, p. 165.

(282.) Kates, 1990, pp. 10-11.

(283.) Bloom et al., 1991, p. 155.

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FIGURE 54

AT EACH SUCCESSIVE REPRODUCTIVE STAGE, FEWER, AND INCREASINGLY
DISADVANTAGED, TEENAGERS...

Although most teenage women do not proceed from one reproductive stage
to the next...

Reproductive stage Women 15-19 Men 15-19




All women and men aged 15-19, 1994 8,565,000 9,009,000
Sexually experienced 4,856,000 5,441,000
Using no contraceptive at first
intercourse 1,685,000 2,279,000
Becoming pregnant or causing
pregnancy 1,003,000 na
Becoming a parent 517,000 186,000
Becoming a parent outside marriage 312,000 140,000

Reproductive stage % of women aged
 15-19 who are
 poor or low-
 income, 1994

All women and men aged 15-19, 1994 38%
Sexually experienced 42%
Using no contraceptive at first
intercourse 53%
Becoming pregnant or causing
pregnancy 73%
Becoming a parent 83%
Becoming a parent outside marriage 85%

Sources: Women and men aged 15-19, 1994: J.C. Day, "Population
Projections of the United States, by Age, Sex, Race, and Hispanic
Origin: 1992 to 2050," Current Population Reports, Series P-25, No.
1092, 1992, Table 2, p.16. Women sexually experienced and women using no
contraceptive at first intercourse: AGI tabulations of data from the
1988 National Survey of Family Growth. Men sexually experienced and men
using no contraceptive at first inter course: F.L. Sonenstein, J.H.
Pleck, and L.C. Ku, "Sexual Activity, Condom Use and AIDS Awareness
Among Adolescent Males," Family Planning Perspective, 21: 152-158, 1989,
Tables 1 and 5, pp. 153 and 155. Women becoming pregnant: S.K. Henshaw,
"U.S. Teenage Pregnancy Statistics," AGI, New York, 1993. Women and men
becoming parents (total and outside marriage):

Note: Table made from bar graph


AGI tabulations of data from the 1988 National Maternal and Infant Health Survey; tabulations of data from the 1987 AGI Abortion Patient Survey. % of women who are pear or low-income, 1994: AGI tabulations of data from the March 1992 Current Population Survey.

Notes: na: not available: the number of men aged 15-19 causing pregnancy cannot be calculated because data on the age of men involved in pregnancies ending in abortion are not available. Data for 1994: Estimated by applying the most recently available gender-specific and, for women, poverty status-specific, proportions of persons at each reproductive stage to the projected number of persons aged 15-19 of that gender in 1994. This assumes that trends will remain constant from the year the proportions were derived.
...AND VERY DIFFERENT INTERVENTION SERVICES NEEDED

...those who do are likely to be already disadvantaged and to need more
intensive intervention services.

Sexuality Contraceptive Outreach Options Abortion Prenatal
education services counseling services care


*
* *
* * *
* * * * * *
* * * * *
* * * * *

Sexuality Adoption School completion Parental
education counseling programs Child care skills


*
*
*
*
* * * * *
* * * * *

Sexuality Programs to Welfare and Child
education become economically Medicaid support
 self-sufficient

*
*
*
*
* * *
* * * *

Note: Table made from bar graph
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