Journal of Youth and Adolescence, Vol. 6, No. 4, 19 77
Can the First Pregnancy of a Young Adolescent Be Prevented? A Question Which Must Be Answered 1 Michael Baizerman 2
Received January 3, 1977
The title o f this paper is a question, and the text o f the paper presents some issues and ideas which are the sources o f the question. Included are notions from the literature on adolescent cognitive development and their relation with the notion o f "prevention. " I t is argued that the notion o f prevention is taken for granted in professional thinking about adolescent pregnancy and that a fuller understanding o f this Mea in the context o f adolescent cognitive development couM have clear consequences for research action.
INTRODUCTION This is an idea paper given focus by a question: " D o girls at the onset o f menses understand the idea o f (pregnancy) p r e v e n t i o n ? ''3 The q u e s t i o n can be written m o r e simply: "Can the first pregnancy o f the y o u n g adolescent be prev e n t e d ? " The substance o f this paper is the answer to this question.
The ideas in this paper were developed while the author was designing an adolescent pregnancy research project financed by a planning grant fro.m the Agricultural Experiment Station, University of Minnesota. 1This article is an expanded version of a paper prepared for presentation at the annual meeting of the National Alliance Concerned with School-Age Parents, Dallas, Texas, November 1976. 2Associate Professor, Center for Youth Development and Research, and in Maternal and Child Health, School of Public Health, University of Minnesota. Received his Ph.D. from University of Pittsburgh. Current research interests include adolescent health, p~ostitution, and car accidents. 3This idea was presented in an outline in Baizerman (1976a). 343 This j o u r n a l is c o p y r i g h t e d by Plenum. Each article is available for $7.50 f r o m Plenum Publishing C o r p o r a t i o n , 2;)7 West 17th Street, N e w Y o r k , N.Y. 10011.
BACKGROUND OF THE QUESTION There is a voluminous literature about adolescent sexuality and adolescent pregnancy (e.g., Baizerman, 1974). Adolescent pregnancy is a social problem. In the literature and at conferences about this problem, six recent youth patterns have been identified: (1) the youth cohort is the largest in the country's history; (2) the absolute number of pregnant adolescents has risen, while the overall rate of adolescent pregnancy has remained almost stable; (3) the rate of very young girls who become pregnant is rising; (4) many more pregnant adolescents choose to keep their babies; (5) the illegitimacy rate is going up (due in part to the increase in pregnancies among very young girls who cannot and choose not to get married); (6) abortions for young teenagers exceed the number of live births. When data are examined by race, the largest increase in pregnancies is found among young Whites, contrary to what is believed by many. These patterns contribute to adolescent pregnancy being defined as a problem in the full sociological sense. Aspects of the social problem include the relatively fewer infants available for adoption (and, in turn, a black market for babies); increasing awareness of infant and child maltreatment by young mothers; the probabilities of infant developmental retardation because of the mother's own physiological development (which contributes to a relatively higher rate of low birth weight and premature infants); the contribution of early pregnancy to the decision to drop out of high school and the subsequent limitations on immediate job opportunities, later educational opportunities, and later occupation career choices. In turn, these are all related to the higher potential of achieving only a relatively low income status. In some communities, these girls also have more limited marriage opportunities (hence, that route to a higher income is partly closed). These aspects of the social problem of adolescent pregnancy have already been discussed (e.g. Baizerman, 1974; Furstenberg, 1976). Note that some of these consequences of pregnancy on the infant, the mother and the biological father, and their parents may be more severe when the girl is very young, that is, 10-13-years-old. Changing social norms and values inform public debate and often result in new aspects of a situation being defined as problematic; and, in turn, these problematic aspects are often joined to the more established social problem. This process is seen in the recent inclusion of parenting skills and deficits in the public discussion of adolescent pregnancy as a social problem. A second aspect recently joined to the social problem is the rate of adolescent abortions. Those who for various reasons oppose abortion find the adolescents' relative lack of parenting skills to be a focusing preventive and remedial effort. Abortion and parenting are joined to youth rights as other emergent legal and moral aspects of adolescent pregnancy. The legal issue crosses such domains
Can First Pregnancy Be Prevented
as school, medical and health care, juvenile justice and public welfare. In schools, the issues of a legal right to education for the pregnant youth is primary, with the moral right to bring the infant to school being another issue. Access to medical and health care prenatally, at delivery, and postpartum are issues, as are the adolescent's legal and moral rights of access to contraceptive information, counseling, and devices. In the domains of juvenile justice and public welfare, the legal and moral issues concern the mother's right to keep or to give away the infant and the right of mother and child to receive public assistance, including housing payments. Together these are aspects of adolescent pregnancy as a social problem. Within this social context the question that gives focus to this paper is raised.
PREVIEW OF THE ANSWER An answer to the question will be given after five sets of information have been presented and discussed. To facilitate the listener's understanding, the five sets are presented first in the outline. Age of Menarche Recent research suggests that the age at the onset of menses has decreased in the United States over the last one hundred years and the median age is now about 12-13 years. (National Center for Health Statistics, 1973). 4 Racial differences have been reported, particularly between younger Black and White girls. More young Blacks than Whites have begun menstruation by the age of 11 years (21.3% versus 11.6%) and by the age of 12 years (51.2% versus 41.7%). After 12 years of age, the percentages between the races are similar. That is to say, there is a larger increase in the number of White (compared to Black) girls who begin menarche between their eleventh and thirteenth years. Overall, about 73% of the girls experienced menarche by their thirteenth year, about 92% by their fourteenth year, and about 98% by their fifteenth year. About one half of the girls had begun menses between their twelfth and thirteenth years. "It Won't Happen to Me" The literature about youth suggests that this period is characterized by a sense that "things which happen to others won't happen to me." Building upon 4Although it can occur before the onset of menses, pregnancy is less likely then.
what Piaget (1972) refers to as "adolescent egocentrism," Elkind (1973) has noted that the adolescent belief in "personal uniqueness becomes a conviction that he will not die, that death will happen to others but not to him"; he calls this part of the youth's "personal fable." As Muuss (1968) states, Piaget has proposed that adolescent egocentrism "takes the form of a naive but exuberant idealism with unrealistic proposals for educational, political and social reforms, attempts at reshaping reality and disregard for actual obstacles." Piaget himself has noted that "the adolescent not only tries to adapt his ego to his social environment but, just as emphatically, tries to adjust the environment to his ego" (quoted by Muuss, 1968). Presented another way, this idea of "invulnerability" can be related to youthful risk-taking behavior, which in turn is part of the "need for exploration and adventure" and the need to "experiment" - needs so characteristic of adolescence (Konopka, 1973). Risk-taking behavior and these needs can also be related to the idea of probability of future events occurring and to the notion of accidents (Baizerman, 1976b). Prediction: It Will Happen versus It May Happen Risk taking is related to the idea of "prediction" and to a probabilistic conception of the world. A risk is not a risk a priori if the outcome is "known" or "very unlikely." To understand the idea and experience the feeling that one is not fully in control of events external to oneself is to (begin to) understand as an adolescent and not as a child on these two levels the notions of risk, accident, and experimentation. It is to understand and experience the notion that the future is problematic and may not happen the way one predicts. To understand the idea of a probabilistic world, it is thought, the youth must be capable of "formal reasoning" in Piaget's term. Young girls and boys may not have reached this stage of cognitive development (as will be discussed below). To understand probability as an idea and to experience it as a feeling is to know about "the odds" and about "chance." It is to know the opposite of the invariant (e.g., that a finger put on a hot stove will feel pain). Beyond knowing in this phenomenological sense, to intellectually understand probability is to know that odds are given often for classes of events or for classes of people and classes of events. And it is to know that the odds of an event occurring to one person is different than the odds of an event occurring in a class of people and a class of events. This is crucial. For example, if the odds for pregnancy among unprotected girls who have intercourse who have begun menses is 2 in 10, (all things being equal), this does not mean that a girl can act once without risk of pregnancy. In this example,
Can First Pregnancy Be Prevented
every individual act has a 1-in-2 probability of resulting in pregnancy (again,
ceteris paribus). Adolescent Cognitive Development There is a very large literature about "cognitive development" in general and specifically in relation to adolescence. In essence the idea is that humans can be shown to change in the logical structure of their thinking, that these changes occur over time, that this time can be conceived of as stages and that these stages can be differentiated empirically. Among the major theorists of this conception of development are Piaget (e.g., 1972), Elkind (e.g., 1973, 1975), and Ausubel and Ausubel (e.g., 1973). More recent work has been reported by Dulit (1972) and by Ross (1973); research about pregnant adolescents and cognitive development has been reported by Cobliner (1974). Research about cognitive development and understanding of sexuality is reported by Bernstein (1976). A related literature on youth moral development was stimulated by Kohlberg (1971), among others. Here, only the briefest note is made of these ideas in order to stimulate interest and thinking. Very simply, the Piagetian conception of cognitive development is called "genetic epistemology." Focus is on "cognition," not emotion. Within the domain of cognition, focus is on logical form, not on content. It is proposed in this conception of cognitive development that adolescence is distinguished from childhood in part by a change from the style of cognition called "concrete stage" thinking to that called "formal operational" thinking. Other words for formal stage thinking are "propositional" and "abstract" (Dulit, 1972). According to Dulit, Perhaps the single most important hallmark of the formal stage, according to Piaget, is the reversal of the relation between concrete reality (actuality) and possibility. In the concrete stage, actuality is in the foreground. In the formal stage.., possibility comes to the foreground. New possibilities can be derived and are derived from recombinations of the variables inherent in the problem, without regard to whether they were even previously actualized or experienced. Theoretically, it is proposed that the concrete stage spans roughly the ages o f 7-11 years, while formal stage thinking begins roughly at about age 11. To this distinction between stages is added Piaget's thought, reported by Cobliner (1974), that there is a distinction "between two levels or kinds of thinking": The first is figurative thinking, the second is operative thinking. Figurative thinking is that which is essentially set in motion by sensory input; it apprehends states and situations . . . . The hallmark of operative thinking is anticipation. This type of thinking transposes future situations into the present and transforms reality, so that the imagined future constantly mobilizes in us the needed resources for ae-
Baizerman tively dealing with contingencies that be far ahead which we conjure up in our minds.
Operative thinking and formal thinking are related. Here again, interest is in the ideas and not in their empirical status with respect to age and sex, and other variables (e.g., Ross (1973).) s The Idea of Prevention Prevention means to keep something or some event from occurring. Medical and public health usage distingushes between primary, secondary, and tertiary levels o f prevention. In this usage, primary prevention can be understood as keeping a thing or event from occurring the first time for the person or population. Secondary prevention means halting, slowing down, or changing a disease or event, and tertiary prevention means rehabilitating the victim o f the thing or event. 6 Simply put, prevention is a probabilistic action o f one or more types: (a) Do x to make y happen. (b) D o n ' t do x to make y happen. (c) Do x to keep y from happening. (d) D o n ' t do x to keep y from happening, x and y can be any actions with health consequences such as brushing teeth, eating junk food, becoming pregnant, or using contraceptives. In formal thinking terms using set theory, these four types are not distinct; in fact, some are only reformulations of others. However, it is submitted that in phenomenological terms, in symbolic terms, and in respect to attitudes, beliefs, motives, and behaviors, these are distinct types.
THE SOCIAL ASPECTS So far ideas about the young girl and her mode o f thinking have been presented. It remains to place the young girl in a social context. Let us begin with a caution: Young pregnant girls come from all racial and economic groups and live in all parts o f the country. One way to think about the social aspects o f the question is to consider another question: Given a young girl in a specific social context and in a specific
SThe literature on language development and sociocultural differences in language usage is not included here, but is suggestive of the proposition that language is closely linked to the issue of cognitive development and to the issues of the girl's understanding of and her ability to talk about her pregnancy. 6There are differences in usage of these words; some differences are about the idea per se. For a usage different from that given herein, see Clark and MacMahon (1967). The status of prevention as an ideology should be noted.
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sociocultural structure, how easy or difficult is it for her to learn and to understand a valid idea of pregnancy prevention? It is aphoristic to say that there are familial, religious, recreational and other social environments within which the young girl can learn about pregnancy etiology and prevention (however valid or invalid the ideas and facts presented). Obviously, she can learn from a variety of people, such as friends, parents, or schooteachers; and she can learn in a variety of ways, such as talking, reading, or looking at a film. The social aspects of the major question, then, have to do with (1) the girl's social structural position in a family, peer group, school, and the like; and (2) her potential in this structural position to be exposed to valid knowledge about pregnancy and its prevention, to b e able to u n d e r s t a n d this information, (cognitively and linguistically), and to act u p o n it in a "preventive way" (i.e., so that she does not become pregnant). For example, a school may n o t be an exposure if no formal sex education curriculum is given and if the youth does not talk to anyone who goes to the school. If there is no formal curriculum but the "kids talk about sex," school could be an exposure. Another aspect of the social influences on a young girl is also obvious. Those in her role sets may have expectations about whether sexuality or pregnancy can be talked about, in what ways, when, where, and with whom; and they may have social norms about "doing something" with one's pregnancy knowledge or without such knowledge. All of these social norms can "regulate" access to valid information. The last social aspect to be noted is the young girl's own "biographical history," which provides a perspective about her, about "who she is," and "how she came to be as she is."
DISCUSSION We begin this discussion of the ideas presented by repeating the original question: Can the first pregnancy of the young girl be prevented? An answer is suggested by a rewording of the question: Can the young girl of 10-12-years-old understand the idea of prevention? Another rewording makes the question more relevant: Can the 10-12-year-old girl understand that she must act in a certain way to keep herself from becoming pregnant? An additional rewording facilitates (and implies) an answer: Does the 10-12-year-old girl have the cognitive ability to understand that she must always act in certain ways if she wants to increase the chances that she will not become pregnant? One more rewording helps to answer the question: Does the 10-12-year-old girl who has achieved menses have the cognitive ability to understand that she must control her or her partner's sexually intimate behavior in certain ways every time if she wants to decrease
the chances that she will become pregnant? Our final rewording incorporates all five ideas: Does the lO-12-year-old girl who has achieved menses have the cognitive ability to understand and to act in such a way that size can (try to} control her and/or her partner's sexually inthnate behavior in certa& ways every time, regardless o f what her friends do, if she wants to decrease the chances that she will become pregnant? These rewordings incorporate the five sets of ideas presented and discussed earlier. To include the social aspects also discussed, the final rewording can be changed in several ways: First, "does the 10-12-year-old girl" can be written as "do 10-12-year-old girls;" that is, a shift can be made from one person to a population group. Second, social factors, variables, conditions, or context can be included. For example, Do 10-12-year-old white girls who are low income and live in West Virginia . . . . Third, specific sociocultural norms can be introduced: Do young girls 10-12-years-old who talk to their friends about sex . . . . Obviously, combinations of these as well as other social aspects can be included in a further reformulated research question.
IMPLICATIONS OF THE IDEAS PRESENTED
Research. The ideas and the several research questions presented herein can be studied empirically. Such study is urged because of the education and other direct service consequences which could follow if these hypotheses are valid. Education. If valid, these ideas could have major consequences on the curricula in school and public health education. These curricula appear to assume youthful cognitive development and, in turn, youthful ability to master certain content. As Ausubel and Ausubel (1973) note, the sequence, form, and style of the presentation of the content may have to be revised. Direct Human Services. Direct care and treatment given to these young girls is often based upon the unarticulated and unexamined assumptions of their ability to understand pregnancy prevention. Often, direct service workers fail to check whether seeming "ignorance" is simply lack of valid knowledge or also lack of ability to know in the developmental sense, not in the IQ sense. A General Rule
The educator, the parent, and the direct service worker can be sensitized to the issue. Once aware, one can change one's own behavior by asking the girl questions intended to assess her cognitive abilities. All who work with young girls and boys might adopt a general rule: I will ask myself when I am with a youth "what am I taking for granted" about this person?
Can First Pregnancy Be Prevented
351 A FinalNote
It is assumed here that the reader is familiar with some assumptions of cognitive development theory. Ausubel and Ausubel (1973) discuss some issues which can be found in the cognitive development literature. Some of their points are particularly pertinent to our problem: Accept that cognitive development can be thought of as occurring in stages that are "qualitatively discriminable." Allow that there is intergroup and intragroup differences between and among youth in one stage and across stages. Note that "stage" and "differences" refer to a given range of measures of content difficulty and familiarity. Furthermore, it is most important to note that (1) stage transitions do not occur "at once"; (2) "fluctuations" between stages are c o m m o n ; (3) a youth may not show "complete consistency and generality of stage behavior" within one week or m o n t h or "from one subject matter or level of difficulty to another" (4) the youth may show stage movement for new subjects inconsistent with his or her overall stage status. The differences in movement may be on the dimension of time in that "the transition to abstract cognitive functioning" may take place "more rapidly."
REFERENCES Ausubel, D. P., and Ausubel, P. (1973). Cognitive development in adolescence. In Burcky, W. (ed.), Selected Readings in Adolescence, Simon and Schuster, New York. Baizerman, M. (1971). Pregnant adolescents:Review of the literature with abstracts, 19601970. Sharing Suppl. Dec. 31. Baizerman, M. (1974). A critique of the research literature concerning pregnant adolescents, 1960-1970. J. Youth Adoles. 3(1): 61-76. Baizerman, M. (1976a). Pregnant adolescents: Questions and answers from research, practice and theory. Paper presented to Annual Symposium on Child Psychiatry, Texas Research Institute on Mental Sciences, Houston, October (forthcoming). Baizerman, M. (1976b). Was the adolescent pregnancy an accident?: A question and approaches to an answer. Paper prepared for presentation at the annual meeting of the National Alliance Concerned with School-Age Parents, Dallas, November. Clark, D. and MacMahon, B. (eds.) (1967). Preventive Medicine, Little, Brown, Boston. Cobliner, W. G. (1974). Pregnancy in the single adolescent girl: The role of cognitive functions. J. Youth Adoles. 3(1): 17-30. Dulit, E. (1972). Adolescent thinking a la Piaget: The formal stage. J. Youth Adoles. 1(4): 281-302. Furstenberg, F., Jr. (1976). Unplanned Parenthood, Free Press, New York. Kohlberg, L., and Gilligan, C. (1971). The adolescent as a philosopher: The discovery of the self in a post conventional world, Daedalus (Fall): 1051-1086. Konopka, G. (1973). Requirements for healthy development of adolescent youth. Adoles. 8(31): 1-26. Muuss, R. E. Theories o f Adolescence, Random House, New York. National Center for Health Statistics. (1973). Age at Menarche, United States. DHEW Pub. No. (HRA 74-1615), Ser. II, No. 133. Piaget, J. (1972). Intellectual evolution from adolescence to adulthood. Hum. Dev. 1-t 2. Ross, R. J. (1973). Some empirical parameters of formal thinking, Z Youth Adoles. 2(2): 167-178.