Health Care Advocate
Addressing Adolescent Pregnancy With Legislation
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Over the past 40 years, the pregnancy rate of U.S. adolescents ages 15 to 19 has decreased by 57 percent. This decline is due, in part, to the availability of contraception for adolescents, adolescents’ use of long-acting reversible contraception and delayed initiation of sexual activity (Hillard, 2013; Jones, Mosher, & Daniels, 2012;
TIFFANY M. MONTGOMERY LORI FOLKEN MELODY A. SEITZ
Mosher, Jones, & Abma, 2012). In 1970, the adolescent pregnancy rate was 68.3 per 1,000, with rates of 38.8 per 1,000 among 15- to 17-year olds and 114.7 per 1,000 among 18- to 19-year olds (Martin, Hamilton, Osterman, Curtin, &
Abstract Adolescent pregnancy is a concern among many women’s health practitioners. While it is practical and appropriate to work to prevent adolescent pregnancy by educating adolescents in health care clinics, schools and adolescent-friendly community-based organizations, suggesting and supporting legislative efforts to reduce adolescent pregnancy can help address the issue on an even larger scale. This article aims to help nurses better understand current legislation that addresses adolescent pregnancy, and to encourage support of future adolescent pregnancy prevention legislation. DOI: 10.1111/1751486X.12133 Keywords adolescent pregnancy | Congress | legislation | policy | teen pregnancy
http://nwh.awhonn.org
© 2014, AWHONN
277
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Mathews, 2013). Between 1970 and 1979, there was a consistent decrease noted in the adolescent pregnancy rate. Over the next 30 years, the rate continued to decrease, with small increases noted intermittently. The most recent increase in the adolescent pregnancy rate occurred between 2005 (39.7 per 1,000) and 2007 (41.5 per 1,000), but since that time the rate has resumed its decline. In 2012, the adolescent pregnancy rate hit an all-time low of 29.4 per 1,000, with rates of 14.1 per 1,000 among 15- to 17-year olds and 51.4 per 1,000 among 18- to 19-year olds (Martin et al., 2013). Despite this decline, the United States still has one of the highest adolescent pregnancy rates compared with other industrialized countries. More than 305,000 babies were born to 15- to 19-year-old adolescents in 2012 (Martin et al., 2013); most of those pregnancies were unintended or unplanned (Mosher et al., 2012). Many adolescent mothers also have a second
complete the requirements for a high school diploma until they’re in their 20s (Hoffman & Maynard, 2008). Adolescent mothers experience lower levels of self-esteem and are at greater risk for depression, substance abuse and intimate partner violence than nonparenting adolescents (Ruedinger & Cox, 2012).Children born to adolescent parents are at greater risk for abuse and neglect, may have lower cognitive abilities and are more likely to be adolescent parents themselves (Ruedinger & Cox, 2012). Moreover, a significant number of incarcerated adolescents were born to adolescent mothers (CDC, 2012). In addition to its impact on adolescent mothers and their children, adolescent pregnancy has a significant impact on society, affecting both short- and long-term economic resources. Lost revenue associated with adolescent pregnancy totaled an estimated $3.2 billion in 2008, and researchers have found that children born to adolescent mothers pay lower taxes through-
Adolescent mothers experience lower levels of self-esteem and are at greater risk for depression, substance abuse and intimate partner violence than nonparenting adolescents
Tiffany M. Montgomery, MSN, RNC-OB, C-EFM, is a PhD student at the University of California, Los Angeles in Los Angeles, CA. Lori Folken, BSN, RNC-OB, is a perinatal educator at Carle Foundation Hospital in Urbana, IL. Melody A. Seitz, MS, RNCOB, is a clinical nurse educator at the Greater Baltimore Medical Center in Baltimore, MD. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: tmontgomeryrn@gmail. com.
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child before reaching 20 years of age, with approximately 23 percent of repeat pregnancies occurring within 2 years of the birth of the first child (Ruedinger & Cox, 2012). Adolescents of ethnic minorities become pregnant at much higher rates than their white counterparts. With rates of 46.3 and 44 per 1,000, Hispanic and non-Hispanic black adolescents, respectively, have the highest adolescent birth rates, compared with the white adolescent birth rate of 27.4 per 1,000 (Martin et al., 2013). In addition to their higher birth rates, Hispanic and non-Hispanic black women, irrespective of age, also have a higher rates of abortions than their white counterparts—17.8, 28.2 and 8.1 per 1,000, respectively (Centers for Disease Control and Prevention [CDC], 2013).
Consequences of Adolescent Pregnancy The consequences of adolescent pregnancy are far-reaching, having an impact on the adolescent mother, the child and society. Many adolescent mothers drop out of school and don’t
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out their adult life as a result of less education and lower earnings (The National Campaign to Prevent Teen and Unplanned Pregnancy, 2011). In 2010, adolescent pregnancy in the United States cost $9.4 billion (The National Campaign to Prevent Teen and Unplanned Pregnancy, 2013). Of this amount, public sector health care cost $2.1 billion, child welfare cost $3.1 billion and incarceration cost $2 billion.
State Legislation One of the aims of Healthy People 2020 is to decrease the rate of adolescent pregnancy (United States Department of Health and Human Services, 2012). Many state and local government agencies have implemented policies and programs aimed at reducing adolescent pregnancy. Some states provide funding to educate parents of adolescent children to help them feel more comfortable initiating sexual health conversations. States also provide education for adolescents on pregnancy, sexually transmitted infections (STIs) and contraception; condomuse skill building and partner communication
Volume 18
Issue 4
Box 1.
Adolescent Pregnancy Prevention Legislation Year
State
Legislation
Purpose
2002
Hawaii
House Resolution 69
Create a special task force to design the Hawaii After-School Initiative, emphasizing teen pregnancy prevention among middle school students
2003
Illinois
House Bill 1630
Establish a Hispanic/Latino Teen Pregnancy Prevention and Intervention Initiative program, and award a grant to a qualified entity for the purpose of conducting research, education and prevention activities to reduce pregnancy among Hispanic teenagers
2005
Florida
Senate Bill 1650
Create a plan for implementing the Florida Education Now and Babies Later (ENABL) program under s. 411.242 and the Teen Pregnancy Prevention Community Initiative within each county of the services area in which the teen birth rate is higher than the state average
2006
Colorado
House Bill 1351
Implement a statewide pilot program for teen pregnancy and dropout prevention to serve teenagers who are Medicaid recipients
2007
Colorado
House Bill 1292
Require school districts, family resource centers and teen pregnancy prevention programs that offer instruction regarding human sexuality to adopt science-based content standards for such instruction
2007
New York
A. 5569/S. 3579
Reduce the number of unintended pregnancies by increasing access to emergency contraception for women in New York State
2007
Texas
House Bill 2176
Develop a parenting and paternity awareness program for use in the district’s high school health curriculum
2013
Colorado
HB 1081
Establish content standards for the provision of human sexuality courses taught in public schools throughout the state
2013
Illinois
HB 2675/SB 2354
Ensure sexual health curriculum is age-appropriate, evidencebased and medically accurate, and require parental consent for student participation in comprehensive sexual education courses
2013
North Carolina
SB 132
Include instruction in the school health education program on the preventable causes of preterm birth; includes induced abortion as a cause of preterm birth in subsequent pregnancies, as recommended by the North Carolina Child Fatality Task Force
Sources: The National Campaign to Prevent Teen and Unplanned Pregnancy (2007), National Conference of State Legislatures (2013).
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implemented policies and programs aimed at reducing adolescent pregnancy skills. Specifics regarding legislation enacted between 2002 and 2013 can be found in Box 1. Only 22 states and the District of Columbia mandate sexual health education (Guttmacher Institute, 2014). Additionally, 33 states and the District of Columbia mandate HIV education and 37 states and the District of Columbia require school districts to involve parents in sex and/or HIV education. States without sexual health or HIV education mandates include Arizona, Arkansas, Colorado, Florida, Hawaii, Idaho, Louisiana, Massachusetts, Texas and Virginia (Guttmacher Institute, 2014). Texas, Arkansas, Arizona and Louisiana also have the third, fifth, sixth and eighth highest adolescent pregnancy rates in the country (Kost & Henshaw, 2013). While it may be difficult to suggest that legislation is the cause of decreases in teen pregnancy, there seems to be an association between states with liberal adolescent sexual health laws, those encouraging comprehensive sex education and lower teen pregnancy rates.
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Federal Legislation There are many ways in which adolescent pregnancy can be addressed using national legislation. One consideration is the privacy of adolescent patients. Because adolescents worried about breeches of confidentiality often do not seek reproductive health services, nurses working with this population should remain cognizant of and advocate for legislation that protects the confidentiality of adolescents’ health information (Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2010). As there is national legislation to address issues of confidentiality, such as the Health Information Portability and Accountability Act (HIPAA), as well as mandates on circumstances that must be reported (e.g., sexual assault), there are also wide variations in state confidentiality legislation. Thus, nurses should be aware of their duty to the adolescent as well as the state regulations that may prohibit certain forms of confidentiality.
As a result of the Affordable Care Act, most insurance providers offer contraception—whether injected, implanted, inserted or ingested—without being asked for a copay or receiving an increased insurance deductible (National Women’s Law Center, 2013). Those who maintain group health plans sponsored by religious employers, however, may not be able to receive contraception free of charge (United States Department of Health and Human Services, 2013b). Still, it’s now more important than ever for women’s health providers to speak with their adolescent patients about the vast array of contraceptive methods that may be freely available to them. The most recognizable national legislation that promotes a decrease in the rate of STIs and unplanned pregnancy is Title X funding. Family planning is a concept that dates back to 1970, when U.S. President Richard Nixon enacted Title X, the national family planning program (Vamos, Daley, Perrin, Manan, & Buhi, 2011). The purpose of the program was to ensure family planning services were available to anyone who needed them. The types of services offered by family planning programs include patient education, contraception,
Volume 18
Issue 4
Photo © Thinkstock Images / thinkstockphotos.com
Many state and local government agencies have
Health Care
Box 2.
Tips for Addressing State Legislation on Adolescent Pregnancy Define the problem and the consequences of early pregnancy and childbearing. Include adolescent pregnancy and birth data for your state, and if possible for localities within the state. To help make the case for investing in prevention, highlight how much adolescent childbearing costs your state.
Advocate
Set a clear and reasonable goal for your state. Whenever possible, invest in evidence-based approaches. Source: The National Campaign to Prevent Teen and Unplanned Pregnancy (2007).
pregnancy testing and pregnancy counseling among others (Vamos et al., 2011).
H.R. 725/S. 372 New legislation aimed to prevent adolescent pregnancy and STIs has been reintroduced in the 113th Congress. H.R. 725/S. 372: Real Education for Health Youth Act of 2013, is an example of one such bill. The purpose of H.R. 725/S. 375 is “to provide for the reduction of unintended pregnancy and sexually transmitted infections, including HIV, and the promotion of healthy relationships, and for other purposes” (United States Government Printing Office, 2013, p. 1). The legislation, if passed, will authorize 5-year grants to public and private entities for implementation of evidence-based, comprehensive sexual education for adolescents, education of elementary and secondary school teachers in sexual education and adolescent sexual education research. H.R. 725/S. 372 was introduced in both the United States House of Representatives and the Senate on February 14, 2013 (GovTrack.us, 2013). First introduced in the House by Representative Barbara Lee (D-CA) and in the Senate by Senator Frank Lautenberg (D-NJ), the bill now has the support of many members of the House and many Senators. Since its introduction to Congress, H.R. 725 has been referred to the Early Childhood, Elementary, and Secondary Education and Higher Education and Workforce Training subcommittees of the House’s Education and Workforce Committees. It was also referred to the House Energy and Commerce Health subcommittee. Likewise, S. 372
August | September 2014
has been referred to the Senate’s Health, Education, Labor, and Pensions committee (GovTrack. us, 2013). As with many other bills in Congress, H.R. 725/S. 372 has been in committee for quite some time. Because of the lengthy process of creating laws, some bills “die” after being referred to the appropriate committee; that is, they never make it to the entire Congress for a vote. The cause for most bills dying in committee is because more pertinent bills take precedence. In these cases, bills may be reintroduced in future sessions of Congress. However, if other issues become priority for legislators, bills that died in committee in years past may be forgotten. Whether it is through the adoption of H.R. 725/S. 372 or future adolescent pregnancy prevention bills, nurses cannot allow adolescent sexual health to lose significance in the eyes of national legislators.
How to Get Involved As a group, nurses can be a powerful force to advocate for change, yet nurses may not fully embrace a role in legislative advocacy. This may be the result of a legislative process that is unfamiliar, or a misunderstanding of the true impact of health policy advocacy. However, nurses who understand the legislative process and advocacy can affect change to address adolescent pregnancy rates. The adolescent pregnancy prevention advocacy process starts by being knowledgeable of the problem. Nurses at the bedside see the impact of adolescent pregnancy on adolescents and their families. Once nurses identify the problem,
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through EOB and other billing mechanisms, adolescents may not continue to seek reproductive health care. As such, these documents may serve as a barrier to adolescent reproductive health care and nurses may choose to oppose their use for adolescent clinic visits. Once a bill is identified as one that could be helpful (or one that could be harmful), nurses must speak up so that legislators can hear their voices. Supporting or opposing adolescent pregnancy prevention legislation, such as H.R.725/S. 372, can be done by calling and/or emailing your legislators. Another option is scheduling meetings with legislators to talk about adolescent pregnancy. During a legislative visit, nurses can share personal stories, tying them into the proposed bill and explaining how the bill could change lives, for better or worse (Maryland & Gonzalez, 2012). After providing information and sharing a story, nurses can finish the visit by directly asking the legislator to support or oppose the bill.
Nurses must speak up so that legislators can hear their voices they can do some research and get involved with nursing organizations to gain an even greater understanding of the effects of adolescent pregnancy. The next step is finding solutions that can make an impact on adolescent pregnancy. Nurses can support bills that provide evidence-based solutions for adolescent pregnancy or that increase access to health services (Montgomery, 2013). They can also oppose bills that may appear to promote adolescent reproductive health, but may actually hinder educators and health professionals from providing efficient sexual health education and optimum health care. In 2007 and 2009 two such bills were introduced in the House, requiring parents to be notified when an adolescent requested contraception from a Title X clinic; these bills did not become law (Center for Reproductive Rights, 2010). Other bills that nurses may choose to oppose include those that require explanation of benefits (EOB) documents for adolescents who are on their parents’ health insurance. If their parents are made aware of their health care visits
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Legislators are given information from a variety of sources; the information may be that the rate of adolescent pregnancy is decreasing, or that the problem is not a great as other problems in society. Thus, it’s important to maintain their interest in such an important area of health promotion. If there is no state adolescent pregnancy legislation that is helping to educate adolescents and decrease a state’s rate of adolescent pregnancy, nurses can speak with their state legislator(s) about the creation of state legislation. For those unfamiliar with drafting bills, The National Campaign to Prevent Teen and Unplanned Pregnancy provides tips that will help to begin what may seem like an impossible task (see Box 2). Additionally, here are a few examples of different types of legislation that can directly or indirectly affect adolescent pregnancy rates: (1) publicly funded, evidence-based, comprehensive sexual education; (2) skill-building sexual health education including, but not limited to, condom application, condom negotiation and self-esteem/self-worth building; (3) increased access to contraception and health services for adolescents, including testing and treatment for STIs; (4) increased privacy/confidentiality for adolescents.
Volume 18
Issue 4
Photo © Dana Bartekoske / thinkstockphotos.com
How to Make a Case for Legislation in Your State
Conclusion Addressing adolescent pregnancy can help to improve health outcomes for a vulnerable population—those who are very young as well as those identified as ethnic minorities. Nurses who care for pregnant adolescents can have a real impact when they inform their legislators about the real-world issues faced by pregnant adolescents and their offspring. NWH
References Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2010). Confidentiality in adolescent health care [position statement]. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 39(1),127–128; 2010. doi:10.1111/j.1552-6909.2009.01096.x Center for Reproductive Rights. (2010). Adolecents’ access to reproductive health services and information. New York, NY: Author. Retrieved from reproductiverights.org/en/project/adolescents-accessto-reproductive-health-services-andinformation Centers for Disease Control and Prevention (CDC). (2012). Teen pregnancy in the United States. Atlanta, GA: Author. Retrieved from www.cdc.gov/TeenPregnancy/AboutTeenPreg.htm Centers for Disease Control and Prevention (CDC). (2013). Abortion surveillance—United States, 2010. Morbidity and mortality weekly report (Vol. 62). Atlanta, GA: Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Retrieved from www. cdc.gov/mmwr/pdf/ss/ss6208.pdf GovTrack.us. (2013). H.R. 725: Real education for Healthy Youth Act of 2013. Retrieved from www.govtrack.us/ congress/bills/113/hr725#overview Guttmacher Institute. (2014). State policies in brief: Sex and HIV education. New York, NY: Author. Retrieved from www. guttmacher.org/statecenter/spibs/ spib_SE.pdf Hillard, P. J. A. (2013). What is LARC? And why does it matter for adolescents and young adults? Journal of Adolescent Health, 52(4, Suppl.), S1–S5. doi:10.1016/j.jadohealth.2013.02.001
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Hoffman, S. D. & Maynard, R. A. (2008). Kids having kids: Economic costs and social consequences of teen pregnancy. Washington, DC: Urban Press Institute. Jones, J., Mosher, W., & Daniels, K. (2012). Current contraceptive use in the United States, 2006–2010, and changes in patterns of use since 1995. National Health Statistics reports (Vol. 60). Hyattsville, MD: National Center for Health Statistics. Retrieved from www.cdc.gov/ nchs/data/nhsr/nhsr060.pdf Kost, K., & Henshaw, S. (2013). U.S. teenage pregnancies, births and abortions, 2008: State trends by age, race and ethnicity. New York, NY: Guttmacher Institute. Retrieved from www.guttmacher.org/pubs/USTPtrendsState08.pdf Martin, J. A., Hamilton, B. E., Osterman, J. K., Curtin, S. C., & Mathews, T. J. (2013). Births: Final data for 2012. National Vital Statistics reports (Vol. 62). Hyattsville, MD: National Center for Health Statistics. Retrieved from www.cdc.gov/nchs/data/nvsr/nvsr62/ nvsr62_09.pdf Maryland, M., & Gonzalez, R. (2012). Patient advocacy in the community and legislative arenas. OJIN: Online Journal of Issues in Nursing, 17(1). doi:10.3912/ OJIN.Vol17No01Man02 Montgomery, T. (2013, June). Legislation and policy solutions [slide presentation]. Paper presented at the Annual Conference of the Association of Women’s Health, Obstetric and Neonatal Nurses, Nashville, TN. Mosher, W. D., Jones, J., & Abma, J. C. (2012). Intended and unintended births in the United States: 1982–2010. National Health Statistics reports (Vol. 55). Hyattsville, MD: National Center for Health Statistics. Retrieved from www. cdc.gov/nchs/data/nhsr/nhsr055.pdf National Conference of State Legislatures. (2013). State policies on sex education in schools. Denver, CO: Author. Retrieved from www.ncsl.org/research/health/ state-policies-on-sex-education-inschools.aspx National Women’s Law Center. (2013). Contraceptive coverage in the health care law: Frequently asked questions. Washington, DC: Author. Retrieved from www.nwlc.org/sites/default/files/ pdfs/faq_on_cont_covg_rule_fact sheet_5-22-13.pdf
childbearing: Consequences and interventions. Current Opinion in Pediatrics, 24(4), 446–452. The National Campaign to Prevent Teen and Unplanned Pregnancy. (2007). FACT SHEET: State legislation to reduce teen pregnancy. Washington, DC: Author. The National Campaign to Prevent Teen and Unplanned Pregnancy. (2011). Counting it up: The public costs of teen childbearing in California in 2008. Washington, DC: Author. The National Campaign to Prevent Teen and Unplanned Pregnancy. (2013). Counting it up: Key data. Washington, DC: Author. Retrieved from thenationalcampaign.org/sites/default/files/ resource-primary-download/countingit-up-key-data-2013-update.pdf United States Department of Health and Human Services. (2012). Healthy People 2020 summary of objectives. Retrieved from www.healthypeople. gov/2020/topicsobjectives2020/pdfs/ HP2020objectives.pdf United States Department of Health and Human Services. (2013a). Birth rates per 1,000 females ages 15–19, by race/ ethnicity, 1990–2012. Rockville, MD: Office of Adolescent Health. Retrieved from www.hhs.gov/ash/oah/adolescenthealth-topics/reproductive-health/ teen-pregnancy/trends.html United States Department of Health and Human Services. (2013b). Women’s preventative services guidelines. Rockville, MD: Health Resources and Services Administration. Retrieved from www. hrsa.gov/womensguidelines/#footnote2 United States Government Printing Office. (2013). H.R. 725. Washington, DC: Government Printing Office. Retrieved from www.gpo.gov/fdsys/pkg/BILLS113hr725ih/pdf/BILLS-113hr725ih.pdf Vamos, C. A., Daley, E. M., Perrin, K. M., Manan, C. S., & Buhi, E. R. (2011). Approaching 4 decades of legislation in the national family planning program: An analysis of Title X’s history from 1970 to 2008. American Journal of Public Health, 101(11), 2027–2037. doi:10.2105/ajph.2011.300202
Ruedinger, E., & Cox, J. (2012) Adolescent
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Addressing Adolescent Pregnancy With Legislation
O Photo © thinkstockphotos.com
Over the past 40 years, the pregnancy rate of U.S. adolescents ages 15 to 19 has decreased by 57 percent. This decline is due, in part, to the availability of contraception for adolescents, adolescents’ use of long-acting reversible contraception and delayed initiation of sexual activity (Hillard, 2013; Jones, Mosher, & Daniels, 2012;
TIFFANY M. MONTGOMERY LORI FOLKEN MELODY A. SEITZ
Mosher, Jones, & Abma, 2012). In 1970, the adolescent pregnancy rate was 68.3 per 1,000, with rates of 38.8 per 1,000 among 15- to 17-year olds and 114.7 per 1,000 among 18- to 19-year olds (Martin, Hamilton, Osterman, Curtin, &
Abstract Adolescent pregnancy is a concern among many women’s health practitioners. While it is practical and appropriate to work to prevent adolescent pregnancy by educating adolescents in health care clinics, schools and adolescent-friendly community-based organizations, suggesting and supporting legislative efforts to reduce adolescent pregnancy can help address the issue on an even larger scale. This article aims to help nurses better understand current legislation that addresses adolescent pregnancy, and to encourage support of future adolescent pregnancy prevention legislation. DOI: 10.1111/1751486X.12133 Keywords adolescent pregnancy | Congress | legislation | policy | teen pregnancy
http://nwh.awhonn.org
© 2014, AWHONN
277
Advocate
Health Care
Mathews, 2013). Between 1970 and 1979, there was a consistent decrease noted in the adolescent pregnancy rate. Over the next 30 years, the rate continued to decrease, with small increases noted intermittently. The most recent increase in the adolescent pregnancy rate occurred between 2005 (39.7 per 1,000) and 2007 (41.5 per 1,000), but since that time the rate has resumed its decline. In 2012, the adolescent pregnancy rate hit an all-time low of 29.4 per 1,000, with rates of 14.1 per 1,000 among 15- to 17-year olds and 51.4 per 1,000 among 18- to 19-year olds (Martin et al., 2013). Despite this decline, the United States still has one of the highest adolescent pregnancy rates compared with other industrialized countries. More than 305,000 babies were born to 15- to 19-year-old adolescents in 2012 (Martin et al., 2013); most of those pregnancies were unintended or unplanned (Mosher et al., 2012). Many adolescent mothers also have a second
complete the requirements for a high school diploma until they’re in their 20s (Hoffman & Maynard, 2008). Adolescent mothers experience lower levels of self-esteem and are at greater risk for depression, substance abuse and intimate partner violence than nonparenting adolescents (Ruedinger & Cox, 2012).Children born to adolescent parents are at greater risk for abuse and neglect, may have lower cognitive abilities and are more likely to be adolescent parents themselves (Ruedinger & Cox, 2012). Moreover, a significant number of incarcerated adolescents were born to adolescent mothers (CDC, 2012). In addition to its impact on adolescent mothers and their children, adolescent pregnancy has a significant impact on society, affecting both short- and long-term economic resources. Lost revenue associated with adolescent pregnancy totaled an estimated $3.2 billion in 2008, and researchers have found that children born to adolescent mothers pay lower taxes through-
Adolescent mothers experience lower levels of self-esteem and are at greater risk for depression, substance abuse and intimate partner violence than nonparenting adolescents
Tiffany M. Montgomery, MSN, RNC-OB, C-EFM, is a PhD student at the University of California, Los Angeles in Los Angeles, CA. Lori Folken, BSN, RNC-OB, is a perinatal educator at Carle Foundation Hospital in Urbana, IL. Melody A. Seitz, MS, RNCOB, is a clinical nurse educator at the Greater Baltimore Medical Center in Baltimore, MD. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: tmontgomeryrn@gmail. com.
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child before reaching 20 years of age, with approximately 23 percent of repeat pregnancies occurring within 2 years of the birth of the first child (Ruedinger & Cox, 2012). Adolescents of ethnic minorities become pregnant at much higher rates than their white counterparts. With rates of 46.3 and 44 per 1,000, Hispanic and non-Hispanic black adolescents, respectively, have the highest adolescent birth rates, compared with the white adolescent birth rate of 27.4 per 1,000 (Martin et al., 2013). In addition to their higher birth rates, Hispanic and non-Hispanic black women, irrespective of age, also have a higher rates of abortions than their white counterparts—17.8, 28.2 and 8.1 per 1,000, respectively (Centers for Disease Control and Prevention [CDC], 2013).
Consequences of Adolescent Pregnancy The consequences of adolescent pregnancy are far-reaching, having an impact on the adolescent mother, the child and society. Many adolescent mothers drop out of school and don’t
Nursing for Women’s Health
out their adult life as a result of less education and lower earnings (The National Campaign to Prevent Teen and Unplanned Pregnancy, 2011). In 2010, adolescent pregnancy in the United States cost $9.4 billion (The National Campaign to Prevent Teen and Unplanned Pregnancy, 2013). Of this amount, public sector health care cost $2.1 billion, child welfare cost $3.1 billion and incarceration cost $2 billion.
State Legislation One of the aims of Healthy People 2020 is to decrease the rate of adolescent pregnancy (United States Department of Health and Human Services, 2012). Many state and local government agencies have implemented policies and programs aimed at reducing adolescent pregnancy. Some states provide funding to educate parents of adolescent children to help them feel more comfortable initiating sexual health conversations. States also provide education for adolescents on pregnancy, sexually transmitted infections (STIs) and contraception; condomuse skill building and partner communication
Volume 18
Issue 4
Box 1.
Adolescent Pregnancy Prevention Legislation Year
State
Legislation
Purpose
2002
Hawaii
House Resolution 69
Create a special task force to design the Hawaii After-School Initiative, emphasizing teen pregnancy prevention among middle school students
2003
Illinois
House Bill 1630
Establish a Hispanic/Latino Teen Pregnancy Prevention and Intervention Initiative program, and award a grant to a qualified entity for the purpose of conducting research, education and prevention activities to reduce pregnancy among Hispanic teenagers
2005
Florida
Senate Bill 1650
Create a plan for implementing the Florida Education Now and Babies Later (ENABL) program under s. 411.242 and the Teen Pregnancy Prevention Community Initiative within each county of the services area in which the teen birth rate is higher than the state average
2006
Colorado
House Bill 1351
Implement a statewide pilot program for teen pregnancy and dropout prevention to serve teenagers who are Medicaid recipients
2007
Colorado
House Bill 1292
Require school districts, family resource centers and teen pregnancy prevention programs that offer instruction regarding human sexuality to adopt science-based content standards for such instruction
2007
New York
A. 5569/S. 3579
Reduce the number of unintended pregnancies by increasing access to emergency contraception for women in New York State
2007
Texas
House Bill 2176
Develop a parenting and paternity awareness program for use in the district’s high school health curriculum
2013
Colorado
HB 1081
Establish content standards for the provision of human sexuality courses taught in public schools throughout the state
2013
Illinois
HB 2675/SB 2354
Ensure sexual health curriculum is age-appropriate, evidencebased and medically accurate, and require parental consent for student participation in comprehensive sexual education courses
2013
North Carolina
SB 132
Include instruction in the school health education program on the preventable causes of preterm birth; includes induced abortion as a cause of preterm birth in subsequent pregnancies, as recommended by the North Carolina Child Fatality Task Force
Sources: The National Campaign to Prevent Teen and Unplanned Pregnancy (2007), National Conference of State Legislatures (2013).
August | September 2014
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implemented policies and programs aimed at reducing adolescent pregnancy skills. Specifics regarding legislation enacted between 2002 and 2013 can be found in Box 1. Only 22 states and the District of Columbia mandate sexual health education (Guttmacher Institute, 2014). Additionally, 33 states and the District of Columbia mandate HIV education and 37 states and the District of Columbia require school districts to involve parents in sex and/or HIV education. States without sexual health or HIV education mandates include Arizona, Arkansas, Colorado, Florida, Hawaii, Idaho, Louisiana, Massachusetts, Texas and Virginia (Guttmacher Institute, 2014). Texas, Arkansas, Arizona and Louisiana also have the third, fifth, sixth and eighth highest adolescent pregnancy rates in the country (Kost & Henshaw, 2013). While it may be difficult to suggest that legislation is the cause of decreases in teen pregnancy, there seems to be an association between states with liberal adolescent sexual health laws, those encouraging comprehensive sex education and lower teen pregnancy rates.
280
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Federal Legislation There are many ways in which adolescent pregnancy can be addressed using national legislation. One consideration is the privacy of adolescent patients. Because adolescents worried about breeches of confidentiality often do not seek reproductive health services, nurses working with this population should remain cognizant of and advocate for legislation that protects the confidentiality of adolescents’ health information (Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2010). As there is national legislation to address issues of confidentiality, such as the Health Information Portability and Accountability Act (HIPAA), as well as mandates on circumstances that must be reported (e.g., sexual assault), there are also wide variations in state confidentiality legislation. Thus, nurses should be aware of their duty to the adolescent as well as the state regulations that may prohibit certain forms of confidentiality.
As a result of the Affordable Care Act, most insurance providers offer contraception—whether injected, implanted, inserted or ingested—without being asked for a copay or receiving an increased insurance deductible (National Women’s Law Center, 2013). Those who maintain group health plans sponsored by religious employers, however, may not be able to receive contraception free of charge (United States Department of Health and Human Services, 2013b). Still, it’s now more important than ever for women’s health providers to speak with their adolescent patients about the vast array of contraceptive methods that may be freely available to them. The most recognizable national legislation that promotes a decrease in the rate of STIs and unplanned pregnancy is Title X funding. Family planning is a concept that dates back to 1970, when U.S. President Richard Nixon enacted Title X, the national family planning program (Vamos, Daley, Perrin, Manan, & Buhi, 2011). The purpose of the program was to ensure family planning services were available to anyone who needed them. The types of services offered by family planning programs include patient education, contraception,
Volume 18
Issue 4
Photo © Thinkstock Images / thinkstockphotos.com
Many state and local government agencies have
Health Care
Box 2.
Tips for Addressing State Legislation on Adolescent Pregnancy Define the problem and the consequences of early pregnancy and childbearing. Include adolescent pregnancy and birth data for your state, and if possible for localities within the state. To help make the case for investing in prevention, highlight how much adolescent childbearing costs your state.
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Set a clear and reasonable goal for your state. Whenever possible, invest in evidence-based approaches. Source: The National Campaign to Prevent Teen and Unplanned Pregnancy (2007).
pregnancy testing and pregnancy counseling among others (Vamos et al., 2011).
H.R. 725/S. 372 New legislation aimed to prevent adolescent pregnancy and STIs has been reintroduced in the 113th Congress. H.R. 725/S. 372: Real Education for Health Youth Act of 2013, is an example of one such bill. The purpose of H.R. 725/S. 375 is “to provide for the reduction of unintended pregnancy and sexually transmitted infections, including HIV, and the promotion of healthy relationships, and for other purposes” (United States Government Printing Office, 2013, p. 1). The legislation, if passed, will authorize 5-year grants to public and private entities for implementation of evidence-based, comprehensive sexual education for adolescents, education of elementary and secondary school teachers in sexual education and adolescent sexual education research. H.R. 725/S. 372 was introduced in both the United States House of Representatives and the Senate on February 14, 2013 (GovTrack.us, 2013). First introduced in the House by Representative Barbara Lee (D-CA) and in the Senate by Senator Frank Lautenberg (D-NJ), the bill now has the support of many members of the House and many Senators. Since its introduction to Congress, H.R. 725 has been referred to the Early Childhood, Elementary, and Secondary Education and Higher Education and Workforce Training subcommittees of the House’s Education and Workforce Committees. It was also referred to the House Energy and Commerce Health subcommittee. Likewise, S. 372
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has been referred to the Senate’s Health, Education, Labor, and Pensions committee (GovTrack. us, 2013). As with many other bills in Congress, H.R. 725/S. 372 has been in committee for quite some time. Because of the lengthy process of creating laws, some bills “die” after being referred to the appropriate committee; that is, they never make it to the entire Congress for a vote. The cause for most bills dying in committee is because more pertinent bills take precedence. In these cases, bills may be reintroduced in future sessions of Congress. However, if other issues become priority for legislators, bills that died in committee in years past may be forgotten. Whether it is through the adoption of H.R. 725/S. 372 or future adolescent pregnancy prevention bills, nurses cannot allow adolescent sexual health to lose significance in the eyes of national legislators.
How to Get Involved As a group, nurses can be a powerful force to advocate for change, yet nurses may not fully embrace a role in legislative advocacy. This may be the result of a legislative process that is unfamiliar, or a misunderstanding of the true impact of health policy advocacy. However, nurses who understand the legislative process and advocacy can affect change to address adolescent pregnancy rates. The adolescent pregnancy prevention advocacy process starts by being knowledgeable of the problem. Nurses at the bedside see the impact of adolescent pregnancy on adolescents and their families. Once nurses identify the problem,
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through EOB and other billing mechanisms, adolescents may not continue to seek reproductive health care. As such, these documents may serve as a barrier to adolescent reproductive health care and nurses may choose to oppose their use for adolescent clinic visits. Once a bill is identified as one that could be helpful (or one that could be harmful), nurses must speak up so that legislators can hear their voices. Supporting or opposing adolescent pregnancy prevention legislation, such as H.R.725/S. 372, can be done by calling and/or emailing your legislators. Another option is scheduling meetings with legislators to talk about adolescent pregnancy. During a legislative visit, nurses can share personal stories, tying them into the proposed bill and explaining how the bill could change lives, for better or worse (Maryland & Gonzalez, 2012). After providing information and sharing a story, nurses can finish the visit by directly asking the legislator to support or oppose the bill.
Nurses must speak up so that legislators can hear their voices they can do some research and get involved with nursing organizations to gain an even greater understanding of the effects of adolescent pregnancy. The next step is finding solutions that can make an impact on adolescent pregnancy. Nurses can support bills that provide evidence-based solutions for adolescent pregnancy or that increase access to health services (Montgomery, 2013). They can also oppose bills that may appear to promote adolescent reproductive health, but may actually hinder educators and health professionals from providing efficient sexual health education and optimum health care. In 2007 and 2009 two such bills were introduced in the House, requiring parents to be notified when an adolescent requested contraception from a Title X clinic; these bills did not become law (Center for Reproductive Rights, 2010). Other bills that nurses may choose to oppose include those that require explanation of benefits (EOB) documents for adolescents who are on their parents’ health insurance. If their parents are made aware of their health care visits
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Legislators are given information from a variety of sources; the information may be that the rate of adolescent pregnancy is decreasing, or that the problem is not a great as other problems in society. Thus, it’s important to maintain their interest in such an important area of health promotion. If there is no state adolescent pregnancy legislation that is helping to educate adolescents and decrease a state’s rate of adolescent pregnancy, nurses can speak with their state legislator(s) about the creation of state legislation. For those unfamiliar with drafting bills, The National Campaign to Prevent Teen and Unplanned Pregnancy provides tips that will help to begin what may seem like an impossible task (see Box 2). Additionally, here are a few examples of different types of legislation that can directly or indirectly affect adolescent pregnancy rates: (1) publicly funded, evidence-based, comprehensive sexual education; (2) skill-building sexual health education including, but not limited to, condom application, condom negotiation and self-esteem/self-worth building; (3) increased access to contraception and health services for adolescents, including testing and treatment for STIs; (4) increased privacy/confidentiality for adolescents.
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Photo © Dana Bartekoske / thinkstockphotos.com
How to Make a Case for Legislation in Your State
Conclusion Addressing adolescent pregnancy can help to improve health outcomes for a vulnerable population—those who are very young as well as those identified as ethnic minorities. Nurses who care for pregnant adolescents can have a real impact when they inform their legislators about the real-world issues faced by pregnant adolescents and their offspring. NWH
References Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2010). Confidentiality in adolescent health care [position statement]. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 39(1),127–128; 2010. doi:10.1111/j.1552-6909.2009.01096.x Center for Reproductive Rights. (2010). Adolecents’ access to reproductive health services and information. New York, NY: Author. Retrieved from reproductiverights.org/en/project/adolescents-accessto-reproductive-health-services-andinformation Centers for Disease Control and Prevention (CDC). (2012). Teen pregnancy in the United States. Atlanta, GA: Author. Retrieved from www.cdc.gov/TeenPregnancy/AboutTeenPreg.htm Centers for Disease Control and Prevention (CDC). (2013). Abortion surveillance—United States, 2010. Morbidity and mortality weekly report (Vol. 62). Atlanta, GA: Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Retrieved from www. cdc.gov/mmwr/pdf/ss/ss6208.pdf GovTrack.us. (2013). H.R. 725: Real education for Healthy Youth Act of 2013. Retrieved from www.govtrack.us/ congress/bills/113/hr725#overview Guttmacher Institute. (2014). State policies in brief: Sex and HIV education. New York, NY: Author. Retrieved from www. guttmacher.org/statecenter/spibs/ spib_SE.pdf Hillard, P. J. A. (2013). What is LARC? And why does it matter for adolescents and young adults? Journal of Adolescent Health, 52(4, Suppl.), S1–S5. doi:10.1016/j.jadohealth.2013.02.001
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Hoffman, S. D. & Maynard, R. A. (2008). Kids having kids: Economic costs and social consequences of teen pregnancy. Washington, DC: Urban Press Institute. Jones, J., Mosher, W., & Daniels, K. (2012). Current contraceptive use in the United States, 2006–2010, and changes in patterns of use since 1995. National Health Statistics reports (Vol. 60). Hyattsville, MD: National Center for Health Statistics. Retrieved from www.cdc.gov/ nchs/data/nhsr/nhsr060.pdf Kost, K., & Henshaw, S. (2013). U.S. teenage pregnancies, births and abortions, 2008: State trends by age, race and ethnicity. New York, NY: Guttmacher Institute. Retrieved from www.guttmacher.org/pubs/USTPtrendsState08.pdf Martin, J. A., Hamilton, B. E., Osterman, J. K., Curtin, S. C., & Mathews, T. J. (2013). Births: Final data for 2012. National Vital Statistics reports (Vol. 62). Hyattsville, MD: National Center for Health Statistics. Retrieved from www.cdc.gov/nchs/data/nvsr/nvsr62/ nvsr62_09.pdf Maryland, M., & Gonzalez, R. (2012). Patient advocacy in the community and legislative arenas. OJIN: Online Journal of Issues in Nursing, 17(1). doi:10.3912/ OJIN.Vol17No01Man02 Montgomery, T. (2013, June). Legislation and policy solutions [slide presentation]. Paper presented at the Annual Conference of the Association of Women’s Health, Obstetric and Neonatal Nurses, Nashville, TN. Mosher, W. D., Jones, J., & Abma, J. C. (2012). Intended and unintended births in the United States: 1982–2010. National Health Statistics reports (Vol. 55). Hyattsville, MD: National Center for Health Statistics. Retrieved from www. cdc.gov/nchs/data/nhsr/nhsr055.pdf National Conference of State Legislatures. (2013). State policies on sex education in schools. Denver, CO: Author. Retrieved from www.ncsl.org/research/health/ state-policies-on-sex-education-inschools.aspx National Women’s Law Center. (2013). Contraceptive coverage in the health care law: Frequently asked questions. Washington, DC: Author. Retrieved from www.nwlc.org/sites/default/files/ pdfs/faq_on_cont_covg_rule_fact sheet_5-22-13.pdf
childbearing: Consequences and interventions. Current Opinion in Pediatrics, 24(4), 446–452. The National Campaign to Prevent Teen and Unplanned Pregnancy. (2007). FACT SHEET: State legislation to reduce teen pregnancy. Washington, DC: Author. The National Campaign to Prevent Teen and Unplanned Pregnancy. (2011). Counting it up: The public costs of teen childbearing in California in 2008. Washington, DC: Author. The National Campaign to Prevent Teen and Unplanned Pregnancy. (2013). Counting it up: Key data. Washington, DC: Author. Retrieved from thenationalcampaign.org/sites/default/files/ resource-primary-download/countingit-up-key-data-2013-update.pdf United States Department of Health and Human Services. (2012). Healthy People 2020 summary of objectives. Retrieved from www.healthypeople. gov/2020/topicsobjectives2020/pdfs/ HP2020objectives.pdf United States Department of Health and Human Services. (2013a). Birth rates per 1,000 females ages 15–19, by race/ ethnicity, 1990–2012. Rockville, MD: Office of Adolescent Health. Retrieved from www.hhs.gov/ash/oah/adolescenthealth-topics/reproductive-health/ teen-pregnancy/trends.html United States Department of Health and Human Services. (2013b). Women’s preventative services guidelines. Rockville, MD: Health Resources and Services Administration. Retrieved from www. hrsa.gov/womensguidelines/#footnote2 United States Government Printing Office. (2013). H.R. 725. Washington, DC: Government Printing Office. Retrieved from www.gpo.gov/fdsys/pkg/BILLS113hr725ih/pdf/BILLS-113hr725ih.pdf Vamos, C. A., Daley, E. M., Perrin, K. M., Manan, C. S., & Buhi, E. R. (2011). Approaching 4 decades of legislation in the national family planning program: An analysis of Title X’s history from 1970 to 2008. American Journal of Public Health, 101(11), 2027–2037. doi:10.2105/ajph.2011.300202
Ruedinger, E., & Cox, J. (2012) Adolescent
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