Am Fam Physician. 2004;70(8):1457-1458
Adolescent pregnancy and its prevention are topics that excite intense controversy. In this issue of American Family Physician, As-Sanie and colleagues1 describe the impact of this public health problem and outline strategies to address it. Despite recent declines, teenage pregnancy rates in the United States still are far higher than rates in comparable countries. Approximately 850,000 American teenagers become pregnant each year.2 Although we are making progress in lowering those rates, we still have a long way to go.
Teenage pregnancy and sexual activity are complex behavioral phenomena, and prevention efforts must do more than provide adolescents with information about the risks and consequences of their behavior. Moreover, focusing exclusively on adolescent girls overlooks the key roles of boys, men, parents, families, and entire communities in teenage pregnancy and its prevention.
Adolescent pregnancy is not just about sex; it is a symptom of young people taking risks. Although sexuality is integral to teenage pregnancy, many nonsexual risk factors and protective factors affect adolescents’ sexual risk-taking. Typically, teenage pregnancy and childbearing reflect low expectations. Young people who see bright futures for themselves, who feel connected to parents and school, and who have many positive factors in their lives take fewer unhealthy risks of any kind and are less likely to experience a pregnancy.3,4 Through research, the Search Institute4 has identified “40 Developmental Assets” that serve as building blocks for healthy development, and that help young people grow up healthy, caring, and responsible.4 Categories of external assets include support, empowerment, boundaries and expectations, and constructive use of time. Internal asset categories include commitment to learning, positive values, social competencies, and positive identity.
One prominent controversy in teenage pregnancy prevention is whether to include positive information on condoms and contraceptives in sex-education programs. American adults and teenagers overwhelmingly favor providing information about contraceptives, along with promoting abstinence among adolescents.5 The evidence that this is not a mixed message is reassuring.6 However, federal abstinence-education funding prohibits positive information about condoms and contraceptives, and many “abstinence-only” programs present highly negative messages. The effectiveness of such an approach has not been proven6 and may increase risks for young people who do become sexually active.7 Encouraging abstinence is a valid priority,8 but caution is needed before we adopt as-yet unproven abstinence-promotion strategies, which potentially could cause harm.
A growing body of evidence tells us what works in preventing teenage pregnancy.6 Well-designed sex-education programs can delay sexual debut and improve condom and contraceptive use—and these programs do not increase sexual activity.6 Condom and contraceptive programs in clinics and schools can improve contraceptive use.6 Media programs also may have an impact by helping to change social norms; one community-based abstinence media campaign may have reduced teenage pregnancy rates.9 The most dramatic results in preventing teenage pregnancy come from youth-development interventions that build “developmental assets,” boost skills, provide healthy activities, and treat young people as resources rather than as problems.10 Importantly, young people can respond to positive messages—healthy “norms”—when they feel connected to the person or group endorsing those norms.11
We have much to learn about other important pieces of the teenage pregnancy–prevention puzzle. Effective programs and strategies are needed to enhance parents’ key role in teaching about sex, relationships, and responsibility. In our modern communities, we are only beginning to ensure that all young people have the developmental assets they need.4 Addressing popular cultural influences in the media, many of which undermine public health messages to teenagers, is another daunting challenge.12
Family physicians and other health professionals can and should do many things to help prevent teenage pregnancy. We should advocate for the use of proven, effective programs—including youth development, sex education, and contraceptive programs—in our schools and communities. We can support research into methods to effectively promote abstinence. We can offer respectful, non-judgmental, and confidential care to adolescents, even as we encourage parent-child communication. Most importantly, family physicians, like all adults in the community, can forge caring connections with adolescents, making our health messages more powerful.