Teen Pregnancy and Abortion

TEEN PREGNANCY

Teen pregnancy is a serious concern in America. According to the Alan Guttmacher Institute (AGI), a nonprofit corporation that engages in reproductive health research, policy analysis, and public education, 841,450 teens became pregnant in 2000. (See Figure 5.1.) The United States has the highest rate of teen pregnancies, births, and abortions among Western industrialized countries.

Figure 5.2 compares pregnancy and abortion rates of several countries in the mid-1990s. For the United States, for example, the teenage pregnancy rate in the mid-1990s was about eighty-five pregnancies per one thousand teenage girls. The birth rate is read at the end of the dark bar. Thus, in the mid-1990s, the teenage birth rate in the United States was about fifty-five. The rest of the pregnancies were aborted (the light part of the bar), by either induced abortion or spontaneous abortion (miscarriage). Thus, in the mid-1990s the teenage abortion rate in the United States (including miscarriages) was about thirty abortions per one thousand teenage girls. Note the higher numbers for all three rates for the United States compared with Sweden, France, Canada, and Great Britain.

The AGI reported these figures as part of a study conducted to see what the United States can learn from countries with lower teen pregnancy rates. In its report "Can More Progress Be Made?: Teenage Sexual and Reproductive Behavior in Developed Countries" (Alan Guttmacher Institute, http://www.guttmacher.org/pubs/euroteens_summ.html, 2001), the AGI revealed that sexually active teens in the United States are less likely to use contraceptives, especially highly effective ones such as hormonal methods, primarily because they tend to have shorter sexually intimate relationships than do teens in other developed countries. American teens also are more likely to have had multiple sex partners (more than four) than teens in the other study countries: Sweden, France, Canada, and Great Britain.

The report suggests that the U.S. approach to reducing teen pregnancy focuses on telling teens that it is wrong to start childbearing early, and that this pronouncement is not a great enough deterrent to teens. In addition, the report suggests that the United States does not provide sufficient resources to help teens make responsible choices. The study attributes the other countries' lower rates of teenage pregnancy to parental and governmental support of teenagers by providing information about and access to effective contraception and adequate health services. In addition, the AGI found that government agencies and parents in these countries help teenagers make responsible decisions about sexual relationships, the use of birth control, and the prevention of sexually transmitted diseases (STDs).

Results of the Henry J. Kaiser Family Foundation's (KFF) 2003 "National Survey of Adolescents and Young Adults: Sexual Health Knowledge, Attitudes and Experiences" survey (http://www.kff.org/youthhivstds/3218-index.cfm) appear to support the AGI findings. The results reveal that more than 75% of the teens surveyed want to know more about how to use condoms, how to recognize the signs of STD and human immunodeficiency virus (HIV) infection, what STD and HIV testing involves, and where they can go to get tested for either.

Another AGI report—"Socioeconomic Disadvantage and Adolescent Women's Sexual and Reproductive Behavior: The Case of Five Developed Countries," (Susheela Singh, Jacqueline E. Darroch, Jennifer J. Frost, and the Study Team, Family Planning Perspectives, vol. 33, no. 6, November/December 2001)—suggests that U.S. teens have higher birth rates and pregnancy rates than those in other developed countries because many American teens are "disadvantaged." To improve U.S. teens' sexual and reproductive behavior, the report suggests, strategies are needed to reduce the numbers of young people growing up in disadvantaged conditions and to help those who are disadvantaged overcome the obstacles they face.

Changes in Teen Pregnancy Rates

Teen pregnancy rates vary with age. As Figure 5.3 shows, in 2000 young women ages eighteen to nineteen had a pregnancy rate more than twice as high as those ages fifteen to seventeen. The pregnancy rates for all teenage groups declined dramatically from 1990–91 to 2000: 35% for young women ages fifteen to seventeen, 28% for those ages fifteen to nineteen, and 21% for those ages eighteen to nineteen.

Teen pregnancy rates also vary among the three major racial/ethnic groups in the United States. (See Figure 5.4.) In 2000 pregnancy rates were highest for non-Hispanic African-American teens, and lowest for non-Hispanic whites. The rates for both groups fell between 1990 and 2000: 32% for African-American teens and 37% for white teens. The rates for Hispanic teens (any race) rose from 1990 to 1992 but then declined to 2000 by 19%.

As the map in Figure 5.5 shows, teen pregnancy rates vary dramatically across the United States, from forty-two pregnancies per one thousand female teens in North Dakota to 113 per one thousand female teens in Nevada. Figure 5.6 shows the change in teen pregnancy rates from 1992 to 2000. Although rates declined during that period in all states, the declines ranged from 4.9% in Wyoming to 39.6% in California.

Possible Reasons for Changes in Teen Pregnancy Rates

Some analysts suggest factors that may account for the decline in teen pregnancy include an increase in condom use (perhaps to prevent contracting HIV or other STDs); decreased sexual activity reflecting changing attitudes toward sex before marriage; and the use of newer methods of birth control, such as hormonal implants and injectables.

Conservative analysts discount the increasing use of contraception as being responsible for the lower pregnancy rates. Instead, they attribute the drop in teen pregnancy to the increasing practice of abstinence (not having sex). Some observers note that young people have become more conservative in their attitudes toward casual sex.

Survey research conducted jointly by KFF and Seventeen magazine, the results of which were published in the October 2003 article "SexSmarts," revealed that the large majority of teens surveyed saw "value in waiting" to have sex. Almost all (92%), including those who were sexually active, said that being a virgin in high school was a "good thing" and that teens who choose not to have sex were "supported" in that decision. Teens also acknowledged that delaying sex had a variety of benefits including respect, control, and freedom from worry about sexual health risks such as pregnancy and STDs. Of teens ages fifteen to seventeen who had not yet had sex, 94% said they had not done so for fear of becoming pregnant; 59% report that it was because they did not have access to contraception.

The 2003 KFF survey "National Survey of Adolescents and Young Adults: Sexual Health Knowledge, Attitudes and Experiences" appeared to mirror these sentiments. Most young people responded that there was pressure to have sex by a certain age and that if you have been "seeing someone for a while," then sex generally was expected. Almost two-thirds thought that waiting to have sex might be a "nice idea, but nobody really does"; more than half agreed that once you do have sex it is harder to say "no" the next time. (See Table 5.1.) Compared with whites and Asians, African-American and Hispanic (Latino) teens more frequently reported that abstinence is not a realistic option for young people.

Life Consequences of Teen Pregnancy

Douglas Kirby, in "Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy" (National Campaign to Prevent Teen Pregnancy, http://www.teenpregnancy.org/resources/data/pdf/emeranswsum.pdf, May 2001), pointed out the serious consequences that high teen pregnancy rates have on teenagers, their children, and society at large. According to Kirby:

When teens give birth, their future prospects become more bleak. They become less likely to complete school and more likely to be single parents, for instance. Their children's prospects are even worse—they have less supportive and stimulating home environments, poorer health, lower cognitive development, worse educational outcomes, more behavior problems, and are more likely to become teen parents themselves.

In "Facts & Stats 17: What Happens to Teen Mothers" (http://www.teenpregnancy.org/resources/teens/facts/fact17.asp), the National Campaign to Prevent Teen Pregnancy reports that only 41% of teen mothers earn a high school diploma and just 1.5% earn a college degree by age thirty. They also are more likely to be on welfare and more likely to be single moms. Another publication by the same organization, "Not Just Another Single Issue" (http://www.teenpregnancy.org/resources/data/pdf/notjust.pdf, February 2002), notes that the children of teenage mothers have lower birth weights, increasing the risk of infant death, blindness, deafness, chronic respiratory problems, mental retardation, mental illness, and cerebral palsy. Low birth weight also doubles the chances that a child will be diagnosed with dyslexia, hyperactivity, or another disability. They also are more likely to be abused and neglected and to perform poorly in school. The Campaign also reports that the sons of teenage mothers are 13% more likely to end up in prison, and daughters of teen mothers are 22% more likely to become teen mothers themselves.

An Overview of Teen Pregnancy Outcomes

According to the National Campaign to Prevent Teen Pregnancy, as of May 2005, 34% of young women became pregnant at least once before they reached the age of twenty ("General Facts and Stats," http://www.teenpregnancy.org/resources/data/genlfact.asp), resulting in about 820,000 teen pregnancies per year. Eight in ten teen pregnancies were unintended and 81% involved unmarried teens. According to the Centers for Disease Control and Prevention (CDC), almost one-third of unintended pregnancies end in abortion. In addition, as Figure 5.7 shows, more pregnancies of girls under age fifteen ended in abortion than those of older teens in 2000. Nearly 44% of pregnant teens under age fifteen terminated their pregnancies with induced abortion. About 13% of pregnancies in this age group terminated naturally with miscarriage. About 43% of under-fifteen pregnant teens carried the pregnancy to term and gave birth in 2000. Figure 5.8 shows that the percentage of pregnancies to teens fifteen to nineteen ending in birth decreased in the 1970s and remained slightly below 50% through most of the 1980s. The period from 1990 to 2000 saw an increase in the percentage of teenagers in this age group carrying their pregnancies to term.

PREVENTING TEEN PREGNANCY

Most people begin having sex in their mid- to late teens, and in 2001 6.6% of teens reported first having sex before age thirteen. In that year the median age at first intercourse was 16.5 years; 61% of twelfth graders had participated in sexual intercourse, as had 35% of ninth graders ("Teen Sexual Activity," Henry J. Kaiser Family Foundation, January 2003). By the time they are eighteen years old, six in ten female teens and nearly seven in ten male teens have had sex ("Sexuality Education: Facts in Brief," Alan Guttmacher Institute, http://www.guttmacher.org/pubs/fb_sex_ed02.html, 2002).

There is little agreement on how to prevent teen pregnancy from occurring as a result of these sexual encounters and what the role of sex education and the availability of contraception should be. Whereas countries such as France, Germany, and the Netherlands try to prevent teenage pregnancy through education about sexuality and safe sex, the United States places more emphasis on preventing teenage sex by encouraging abstinence. Many Americans consider the promotion of birth control as an encouragement to teens to be promiscuous and advocate abstinence instead.

Sex Education/Abstinence Education

The 1996 federal welfare reform law, the Personal Responsibility and Work Opportunity Reconciliation Act (PL 104-193), provided an annual $50 million allocation over a five-year period (1998–2002) to states for abstinence education programs. The purpose of these programs was "to enable the State to provide abstinence education, and at the option of the State, where appropriate, mentoring, counseling, and adult supervision to promote abstinence from sexual activity, with focus on those groups which are most likely to bear children out of wedlock." Funded programs are prohibited from teaching birth control, although students requesting information may be given referrals. In addition, the law included an incentive provision, allotting $50 million to be distributed to the top five states that reduce their out-of-wedlock births without increasing abortions during the previous two years. In mid-2003 Congress passed the "Welfare Reform Extension Act of 2003," which reauthorizes the abstinence education program exactly as under the 1996 law. In addition, $5 million is provided annually to support a national teen pregnancy prevention resource center, which would offer technical assistance and work with the media to discourage teen pregnancies.

In a review of thirty-five abstinence-based programs, the World Health Organization found that these programs were less effective in reducing risky sexual practices in teens than programs that promoted delaying first intercourse and safer sex practices. According to Douglas Kirby of the National Campaign to Prevent Teen Pregnancy, there is no evidence that abstinence-only education delays teenage sexual activity. Also, research shows that abstinence-only strategies may discourage contraceptive use among teens who are sexually active. A study by Kirby found that comprehensive sex education programs that provide

information about both abstinence and contraception "do not accelerate the onset of sex, increase the frequency of sex or increase the number of partners—as critics of sex education have long alleged—but can increase the use of contraception when teens become sexually active" (as summarized by Cynthia Dailard in "Abstinence Promotion and Teen Family Planning: The Misguided Drive for Equal Funding," The Guttmacher Report on Public Policy, vol.5, no. 1, February 2002). These findings were underscored in "Call to Action to Promote Sexual Health and Responsible Sexual Behavior," issued by Surgeon General David Satcher in June 2001.

On February 10, 2005, the Responsible Education about Life Act (the REAL Act) (H.R. 768 and S. 368) was introduced in Congress. This bill would provide funding to states for so-called abstinence-plus programs in schools that would provide medically accurate, age appropriate, comprehensive sex education that includes instruction in both abstinence and contraception. The House of Representatives and the Senate referred the bill to committee. As of September 1, 2005, no action had been taken yet on the bill.

As of August 1, 2005, twenty-two states and the District of Columbia mandated sex education in public schools, and thirty-eight states and the District of Columbia mandated STD/HIV education. Twenty-two states required that abstinence be stressed when taught as part of sex education, and eight states required that it be only "covered." Only fourteen states and the District of Columbia required that sex education programs cover contraception, while seventeen states required that STD/HIV programs cover contraception. No state required that contraception be stressed in either sex education classes or STD/HIV prevention classes ("Sex and STD/HIV Education," State Policies in Brief, Alan Guttmacher Institute, August 1, 2005).

Parents and Sex Education

Parental consent requirements or "opt-out" clauses, which allow parents to remove students from instruction the parents find objectionable, may restrict the information adolescents receive. AGI statistics show that as of August 1, 2005, three states required parental consent for students to participate in sex or STD/HIV education, and thirty-six states and the District of Columbia allowed parents to remove their children from these classes.

In the "National Survey of Adolescents and Young Adults," released in 2003, the KFF reported that "sex education in school is also a cornerstone of sexual health information for young people—68% have learned at least 'some,' including 45% who say they have learned a lot, from sex education."

In January 2004 the results of a survey jointly sponsored by National Public Radio, the Henry J. Kaiser Family Foundation, and the Harvard University John F. Kennedy School of Government, were published. The results of "Sex Education in America" (Kaiser Family Foundation, http://www.kff.org/kaiserpolls/pomr012904oth.cfm, January 29, 2004) revealed that 15% of adult Americans believe that schools should use an abstinence-only approach in sex education classes. Nearly half—46%—believe that abstinence-plus is best. That is, schools should teach that abstinence is a primary goal, but they should also teach about condoms and other forms of contraception. Slightly over one-third (36%) believe that abstinence is not the most important thing, and that sex education classes should focus on helping teens learn how to make responsible decisions about sex.

Characteristics of Effective Sex Education Programs

For many years Douglas Kirby was chairperson of the Effective Programs and Research Task Force for the National Campaign to Prevent Teen Pregnancy. In 2001 he completed a study that surveyed the effectiveness of sex education programs across the United States. At that time Kirby noted that more research needed to be conducted because very few sex education programs have been evaluated as to their impact in delaying sexual intercourse among adolescents. Kirby observed that curricula with the most effective sex and HIV education programs share ten important characteristics. In his words, these programs do the following:

• Focus on reducing one or more sexual behaviors that lead to unintended pregnancy or HIV/STD infection
• Are based on theoretical approaches that have been demonstrated to influence other health-related behavior and identify specific important sexual antecedents to be targeted
• Deliver and consistently reinforce a clear message about abstaining from sexual activity and/or using condoms or other forms of contraception. This appears to be one of the most important characteristics that distinguishes effective from ineffective programs
• Provide basic, accurate information about the risks of teen sexual activity and about ways to avoid intercourse or use methods of protection against pregnancy and STDs
• Include activities that address social pressures that influence sexual behavior
• Provide examples of and practice with communication, negotiation, and refusal skills

• Employ teaching methods designed to involve participants and have them personalize the information
• Incorporate behavioral goals, teaching methods, and materials that are appropriate to the age, sexual experience, and culture of the students
• Last a sufficient length of time (i.e., more than a few hours)
• Select teachers or peer leaders who believe in the program and then provide them with adequate training

The National Campaign to Prevent Teen Pregnancy also suggests that successful programs should emphasize activities that instill teens with confidence and a sense of hope for the future. According to Daniel J. Whitaker, Kim S. Miller, and Leslie F. Clark in "Reconceptualizing Adolescent Sexual Behavior: Beyond Did They or Didn't They?" (Family Planning Perspectives, vol. 32, no. 3, May/June 2000), teen sex prevention efforts "must be tailored to the specific needs of teens with varying sexual experiences and expectations, and must address the social and psychological context in which sexual experiences occur." The authors contend that prevention efforts that focus only on delaying sexual onset in teens who have not had sex, and encouraging condom use among teens who already are sexually active, leave out many teens.

Media Influences on Teenage Sex

The number of television shows with sexual content increased significantly from 1998 to 2000. Only one in ten shows that contain sexual content included a reference to safer sex or to the possible risks and responsibilities that go along with having sex. However, there is a trend toward including more of these messages according to the third "Sex on TV: Content and Context" report (Kaiser Family Foundation, http://www.kff.org/entmedia/20030204a-index.cfm, 2003)—a study of the amount and nature of sexual material on television. The report found that the amount of sex on television remains high, but TV programs are more likely to include some reference to issues such as waiting to have sex, using contraception, or the possible consequences of unprotected sex.

The RAND Corporation, a nonprofit research organization, released a study on television and adolescent sexuality in November 2003. Results of this study revealed that teenagers in the United States absorb sex education messages from television programs, and watching and discussing television programs with an adult reinforces the sex education messages. A RAND senior behavioral scientist and colleagues surveyed 506 twelve- to seventeen-year-old viewers of the NBC series Friends about an episode in which the character Rachel tells the character Ross that she became pregnant after they had sex although they used a condom. The episode features two mentions that condoms are only 97% effective at preventing pregnancy when used correctly. Most teen viewers reported that they felt the message of the episode was that "lots of times condoms don't prevent pregnancy." The 40% of teen viewers who watched this particular show with an adult were more likely to accurately remember condoms' effectiveness (97%) in preventing pregnancy than teens who did not watch the episode with an adult.

In a special analysis by KFF of the top twenty shows teen viewers watch, almost half (45%) of the episodes that included a reference to sex also included a reference to a safer sex topic. The study also revealed that safer sex messages were more common in shows that have characters involved in sexual intercourse (26%) and teens in sexual situations (34%)—both nearly twice the rate found four years ago.

When the report was released, KFF Vice President Victoria Rideout said, "From a public health perspective, it's encouraging to see this trend toward greater attention to safer sex issues on TV…. This generation is immersed in the media, so when Hollywood makes safer sex sexier, whether it's abstinence or protection, that's all to the good" ("Study Finds Sex Getting Safer on American TV," Dr. Bob Martin, http://www.doctorbob.com/2003k_02_05news03.html, February 5, 2003).

RAND Corporation researchers published a more extensive study on this subject in the journal Pediatrics in September 2004: "Watching Sex on Television Predicts Adolescent Initiation of Sexual Behavior" (vol. 114, no. 3, http://pediatrics.aappublications.org/cgi/reprint/114/3/e280). In spite of some of the positive references to safer sex and sexual responsibility on television, a major conclusion of the authors of the report was that "watching sex on TV predicts and may hasten adolescent sexual initiation. Reducing the amount of sexual content in entertainment programming, reducing adolescent exposure to this content, or increasing references to and depictions of possible negative consequences of sexual activity could appreciably delay the initiation of coital and non coital activities. Alternatively, parents may be able to reduce the effects of sexual content by watching TV with their teenaged children and discussing their own beliefs about sex and the behaviors portrayed." In this and their previous studies on sex on television and its influence on adolescents, the RAND Corporation notes that:

• Of all shows, 64% have some sexual content, including one in three (32%) containing sexual behaviors (the rest have talk about sex). This rate of sexual content is similar to that found two years before (68%), up from about half of all shows (56%) four years before.

• One in seven shows (14%) include actual sex, either depicted or strongly implied, which is a 4% increase from two years before and a 7% increase from four years before.
• Overall, the percentage of shows with any sexual content—including more modest content such as talk about sex, kissing, or touching—that also included a safer sex reference was 15%, up from 10% two years before and 9% four years before.

Other television programming, some magazines, and some Web sites targeted to teens provide positive, educational messages regarding teen sex and pregnancy. For example, the Black Entertainment Television (BET) cable show Teen Summit features regular programs on teen sexuality. The Channel One News, a nationwide school-based news program involving more than eight million students and four hundred thousand educators, covers issues affecting America's teens. Teen People magazine and the National Campaign to Prevent Teen Pregnancy sponsor a contest each year asking teens to create a magazine advertisement with a message about preventing teen pregnancy. Teen People also has continuing editorial coverage of issues surrounding teen pregnancy, and Sports Illustrated and BET's Heart and Soul magazine have featured teen pregnancy prevention in their public service messages. Kiwibox.com has featured discussions on what it's like to be a teen mother, how to know when you're ready to have sex, and how to prevent pregnancy and STDs.

TRENDS IN SEXUAL RISK BEHAVIORS

Unprotected sexual intercourse and multiple sex partners place young people at risk for pregnancy as well as for HIV infection and other STDs. In "Trends in Sexual Risk Behaviors among High School Students—United States, 1991–2001" (Morbidity and Mortality Weekly Report, vol. 51, no. 38, September 27, 2002), the CDC reported that in the decade 1991–2001 the number of high school students who reported having sex decreased 16% and that those who had multiple sex partners (more than four) decreased 24%. The overall prevalence of current sexual activity did not change.

Among currently sexually active female students, condom use at last sexual intercourse increased from 38% in 1991 to 51.3% in 2001. For males it was 54.5% in 1991, compared with 65.1% in 2001. (See Table 5.2.) The percentage of these students who used alcohol or drugs before their last sexual intercourse, however, increased by 18%.

TEEN BIRTH RATES

In 2001 the CDC reported that the U.S. teen birth rate of 48.7 in 2000 was the highest of twenty-three developed countries ("Births to Teenagers in the United States, 1940–2000," National Vital Statistics Reports, vol. 49, no. 10, September 25, 2001). Of these countries, the Netherlands and Japan had the lowest teen birth rates; the U.S. rate was nine times higher. The Russian Federation had the second-highest birth rate with 44.7 births per one thousand teens in 1995. Figure 5.9 shows teenage birth rates in the United States from 1970 to 2000 compared with the birth rates of teens in England and Wales, Canada, France, and Sweden. American teen birth rates have been much higher for decades than those of the other developed countries shown.

Although teen birth rates are relatively high in the United States compared with other developed countries, there are positive statistics: the birth rate for teens ages fifteen to nineteen years decreased 33% between 1991 and 2003. In 2003 the birth rate for this age group was 41.7. The birth rate also declined dramatically for younger teens ten to fourteen years—down 57% since 1991. In 2003 the birth rate for this age group was 0.6. (See Table 5.3.)

Births to Unmarried Teenagers

Most teens who give birth were unmarried—81.6% overall in 2003, with 343,908 babies born to unmarried teens in that year. (See Table 5.4.) From 2002 to 2003 the number of births to unmarried women of any age increased by 0.6% (from 34% to 34.6%), and births to unmarried teens rose by 1.4% (from 80.2% to 81.6%). Within age subgroups of teens, the largest increase in the number of births to unmarried teens was in the eighteen to nineteen age group.

Race and Ethnicity

In the ten to fourteen age group the largest decline in birth rate was among Asian or Pacific Islanders (API teens). In the eighteen to nineteen age group the largest decline was among Native American teens. Rates in 2003 were highest for Hispanic teenagers and lowest for API teens.

According to the CDC, non-Hispanic African-American teens in the fifteen to nineteen age group experienced the largest drop in birth rates since 1991—a 45% decline from 1991 to 2003. (See Table 5.3.) Figure 5.10 shows the decline in teen birth rates from 1990 to 2002 by racial/ethnic group. The dramatic decline in birth rates of African-American teens is evident, although the birth rate of all groups declined.

Hispanic ("Latina") teens had the highest teen birth rates among the major racial or ethnic groups in the United States from 1995 to 2002, according to the National Campaign to Prevent Teen Pregnancy. (See Figure 5.10.) The 2002 birth rate for Hispanic fifteen- to nineteen-year-olds was 82.9 per one thousand, which was nearly double the national rate of 42.9 per one thousand ("Teen Sexual Activity, Pregnancy and Childbearing among Latinos in the United States," Fact Sheet, National Campaign to

Prevent Teen Pregnancy, http://www.teenpregnancy.org/resources/reading/pdf/latinofs.pdf, May 2004). In 2002 30% of the births to women ages fifteen to nineteen years were to Hispanic teens. This birth rate is higher than that for African-American teens, although Hispanic teens have a lower pregnancy rate, because African-American teens are more likely than Hispanic teens to have an abortion.

State-Specific Birth Rates

In 2002 birth rates for teens ages fifteen to nineteen years ranged from a low of 20.0 births per one thousand female teens in New Hampshire to a high of 64.7 in Mississippi. Although a city, so not directly comparable, the District of Columbia had the highest teen birth rate at 69.1. (See Table 5.5.)

In 2000 in every state, the District of Columbia, the Virgin Islands, and Guam, birth rates for teens ages fifteen to nineteen declined from the rates in 1991. (See Figure 5.11.) Declines ranged from less than 16% in Texas, Arizona, Colorado, Nebraska, Arkansas, Mississippi, Alabama, Georgia, North Carolina, and Rhode Island to 25% or more in Washington, California, Alaska, Hawaii, Michigan, Massachusetts, Vermont, New Hampshire, Maine, and the District of Columbia.

TEEN ABORTION

Abortion rates for teens ages fifteen to nineteen years decreased 40% from 1990 to 2000—from 40.3 per one thousand to 24.0 per one thousand. (See Table 5.6.) The

declines in birth and abortion rates during 1990 and 2000 were 23% and 54%, respectively, for non-Hispanic white teens ages fifteen to nineteen years, 32% and 31% for African-American teens, and 13% and 23% for Hispanic teens, according to the CDC in "Estimated Pregnancy Rates for the United States, 1990–2000: An Update" (National Vital Statistics Report, vol. 52, no. 23, June 15, 2004).

Figure 5.12 shows the pregnancy, birth, and abortion rates for teens ages fifteen to seventeen years from 1976 to 2003. Since 1990 the pregnancy rate for teens decreased 33%, from 80.3 to 53.5, a record low. The birth rate declined 42%, from its peak of 38.6 in 1991 to 22.4 in 2003. The induced abortion rate declined by 53%, from its peak of 30.7 in 1983 to 14.5 in 2000 ("QuickStats: Pregnancy, Birth, and Abortion Rates for Teenagers Aged 15-17 Years—United States, 1976–2003," Morbidity and Mortality Weekly Report, vol. 54, no. 4, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5404a6.htm, February 4, 2005).

Race and Ethnicity

"Abortion Surveillance—United States, 2001" (Morbidity and Mortality Weekly Report, Surveillance Summaries, vol. 53, no. SS-09, November 26, 2004) reports that in 2001, for females whose age and race were known, white teens ages fifteen to nineteen had a greater percentage of abortions (17.9%) than African-American teens (16.3%) or other races (13.8%). (See Table 4.3 in Chapter 4.)

Abortion Ratios

An abortion rate is the number of abortions per one thousand women in the age category considered. An abortion ratio, as defined by the AGI, is the number of abortions per one hundred pregnancies that ended in abortion or live birth—that is, per one hundred pregnancies that did not end in miscarriage. Thus, an abortion ratio is really the percentage of abortions in one hundred pregnancies. Table 5.7 shows abortion rates and abortion ratios from 1973 through 2002 for women ages fifteen to forty-four. Since 1995, approximately one-quarter of all pregnancies that did not end in miscarriage were terminated by induced abortion. Also during those years, about twenty-one women out of every one thousand women ages fifteen to forty-four had an abortion.

The abortion ratio varies by age, and was highest for teens in 2001, as Figure 5.13 shows. These data are from the CDC, which defines abortion ratio as the number of abortions per one thousand live births. The highest abortion ratio in 2001—by far—was that for teens under age fifteen. The next highest abortion ratio was that for teens fifteen to nineteen years old.

Relinquishment for Adoption

A teenager faced with an unintended pregnancy can choose parenthood (often obtaining help from relatives), relinquishing (giving up) the infant for adoption, or abortion. Most women of any age choose to keep their infant or to have an abortion. According to the most recent data published by the CDC, less than 1% of infants born to never-married women under forty-five years of age were relinquished for adoption between 1989 and 1995. This figure is down from 8.7% prior to 1973, 4.1% between 1973 and 1981, and 2% between 1982 and 1988. Relinquishment also occurs among the formerly married and the currently married, but it is very rare ("Adoption, Adoption Seeking, and Relinquishment for Adoption in the United States," Advance Data from Vital and Health Statistics, no. 306, Centers for Disease Control and Prevention, http://www.cdc.gov/nchs/data/ad/ad306.pdf, May 11, 1999).

Clearly, there has been a downward trend in relinquishment of births occurring to never-married women. This decline has paralleled a steady increase in the rate of births to unmarried women reported by the CDC during the same period. The CDC suggests that study is needed to determine the reasons why fewer never-married mothers choose to relinquish their babies for adoption but notes in "Adoption, Adoption Seeking, and Relinquishment for Adoption in the United States" that recent declines in abortion rates suggest that the choice of abortion over relinquishment is not a significant factor in lower prevalence of relinquishment in recent years.

Factors That Affect Pregnancy and Abortion

According to the AGI, factors that affect pregnancy and abortion include the following:

• Marital status—Married teens with unintended pregnancies are less likely than unmarried teens to have an abortion. These teens generally have the support of their spouse and family to carry the pregnancy to term. In addition, married couples are more likely to be employed, have higher incomes, and are more willing to have children. Even so, about one-fourth of married teens with unintended pregnancies obtain an abortion.
• Expectations for the future—In general, teenagers who have a plan for their future are more likely to end their pregnancy. In contrast, teenagers who are ambivalent about their future tend to carry their pregnancy to term.
• Socioeconomic status and parents' education—Teens who come from families that are better off financially and whose parents are more educated tend to have abortions. Those from poor or low-income families and whose parents are less educated tend to choose childbirth.

• The age of the teen's partner—Teenagers with partners who are older are more likely to bear a child.
• Race and ethnicity—White teenagers whose pregnancies are unintended are more likely to have an abortion than are African-American and Hispanic teens.
• Medicaid coverage—Teenagers whose health care is covered by Medicaid are less likely to have an abortion. Most states pay for prenatal care and childbirth but not for abortion.

WHAT DO TEENS KNOW ABOUT ABORTION?

Rebecca Stone and Cynthia Waszak of the Center for Population Options, an organization that supports abortion as an alternative, conducted focus-group studies of teens across the country in 1992 (the latest comprehensive data available) to better understand adolescent attitudes on abortion. (In recent years the federal government has withheld funding from researchers studying abortion—including attitudes on abortion. Thus, up-to-date research on such topics is often not available.) The authors wanted to learn where teens got their information; how they formed their opinions on abortion; how they felt about speaking to their parents about the issue or having to turn to them for consent for the procedure; and whether there were gender, ethnic, or cultural differences in attitude. The results of Stone and Waszak's research were published as "Adolescent Knowledge and Attitudes about Abortion" (Family Planning Perspectives, vol. 24, no. 2, March/April 1992). The authors found surprising consistency in the responses of the eleven focus groups and identified four major themes.

First, most teens held negative attitudes toward abortion, but they felt that women still needed the right to choose. Data from the Gallup poll "Teens Lean Conservative on Abortion," conducted on November 18, 2003, tend to support these ideas. The Gallup poll revealed that 72% of teenagers think that abortion is morally wrong. However, over half think that abortions should be legal—47% saying that abortions should be legal under certain circumstances and 19% saying that abortion should be legal in all circumstances.

Second, teens did not think that mandatory parental involvement was helpful, no matter how strongly the teenagers opposed abortion. Third, they lacked knowledge about abortion and related laws. They relied on anecdotal evidence and often believed that abortion is medically dangerous, emotionally damaging, and widely illegal. Fourth, teens' attitudes toward abortion were generally shaped by antiabortion views, conservative morality, and religion.

Teens, regardless of sex, mentioned "murder, killing a baby, or death" when asked about what the word "abortion" brought to mind. Many felt abortion was something done out of fear of being found out. Most of the females agreed that the male had a right to know if his girlfriend was pregnant and to be included in the decision. Although the participants generally disliked abortion, they condoned abortion in cases of rape and incest. Moreover, they approved of keeping abortion legal, either because they felt women would do it anyway and it was better that it was done right, or because they did not feel it was right to dictate ideas to others.

Although the teens generally disapproved of abortion, they did not approve of requiring parental permission for abortion. Even those who reported open relationships with their parents (mothers in particular) and who claimed they could discuss sex with their parent(s) felt they would have a hard time telling their parents that they wanted an abortion. Even those who felt they could discuss abortion with their parents could imagine circumstances for other teens where it would be very difficult or impossible.

The focus groups revealed teens' lack of understanding about abortion. Teens in the focus groups knew little about the legality of abortion. Only a few were aware of Roe v. Wade or its significance. The participants did not know that abortion is legal in all fifty states, although they seemed to know that it is legal in their own state. The teens held misconceptions about the physical and mental effects of abortion. Many believed that abortion, especially multiple abortions, made a

woman sterile and that it was some kind of cutting procedure that hurt. They also thought it was emotionally devastating.

Stone and Waszak believed that "from a public health perspective, assessing adolescents' views on abortion is critical to devising effective ways to deliver information and services to teenagers in need of pregnancy prevention or pregnancy option counseling." They further believed that, with the high incidence of pregnancies among American teens, there is a need for educating young people not only about pregnancy prevention but also about early, safe abortion.

PARENTAL INVOLVEMENT IN ABORTION DECISIONS

Most state laws require minors (those under the age of eighteen) to either obtain their parents' consent or notify their parents of their intent to get an abortion before they undergo the procedure. These laws generally include judicial bypass provisions if the young woman does not want to or cannot tell her parents of her decision. In a judicial bypass (waiver), the court decides if the minor is mature enough to make the decision on her own or if the abortion would be in her best interests. A Gallup opinion poll conducted in January 2003 found that 73% of adult respondents favored "a law requiring women under 18 to get parental consent for any abortion."

As of 2005 forty-four states had laws requiring a minor seeking an abortion to obtain the consent of or to

notify an adult, usually a parent. (See Table 5.8.) Thirty-three of these laws were enforceable in that year. Among the states with enforceable consent laws, Maryland and Utah did not provide a judicial bypass to enable a minor to bring her case before the court. Six states (Connecticut, Hawaii, New York, Oregon, Vermont, and Washington) and the District of Columbia do not have any form of parental consent law.

Proponents of parental notification or consent laws suggest that adolescents are at a high risk of physiologi-cal and psychological harm from abortion and that adolescents are not able to make an adequately informed decision about abortion. However, Nancy E. Adler, Emily J. Ozer, and Jeanne Tschann in "Abortion among Adolescents" (American Psychologist, vol. 58, no. 3, March 2003) note that abortion carries relatively few medical risks compared with the risks of childbearing. Data from the CDC reveal that overall pregnancy-related death rates in the United States are 9.2 per one hundred thousand live births, whereas overall death rates due to abortion in the United States are 0.3 per one hundred thousand legal abortions. The authors of "Abortion among Adolescents" also note that results of studies of psychological responses following abortion show that the risk of psychological harm is low. After analyzing many studies on the ability of adolescents to make adequate and informed decisions regarding abortion, the authors determined that adolescent abortion patients appear, on the whole, to be competent in their decision-making capabilities. They also note that parental involvement laws aim to promote family communication and functioning but that forcing communication between parents and children about abortion may not have the desired positive effects.