One difference between the United States and the comparison countries was the amount of poverty. The poverty in America is essentially unknown in Canada and in Western Europe. Therefore, the relatively high rate of poverty may be associated with perpetuating adolescent pregnancy.

The United States and comparison countries also differ in societal attitudes toward adolescent sexuality and contraception. The general American attitude is that sex among teenagers is not acceptable. In contrast, the European attitude is less condemning. For example, of the countries in the collaborative study, only the United States had developed government sponsored programs designed to discourage adolescents from becoming sexually active. Contraceptives, particularly oral contraceptives, were more available in foreign countries. In all countries studied except the United States, teenagers reported having easy access to family planning clinics. Furthermore, adolescents who were given contraceptives did not have to obtain parental consent, were assured of confidentiality, and often were not charged a fee. It is noteworthy that countries in which contraceptives were easily available did not have a higher rate of adolescent sexual activity than the United States. Also, at least six other studies to date corroborate this finding that higher availability of contraceptives is not associated with higher rates of adolescent sexual activity.

Psychological Factors

Although sociocultural factors are important correlates of adolescent pregnancy, it is undeniable that many young women are exposed to similar sociocultural environments and do not become pregnant. Psychological and attitudinal factors are also implicated.

Studies suggest that pregnant adolescents differ from nonpregnant adolescents in lower educational motivation and a tendency to be more impulsive. Although these differences exist, they are not strong predictors of adolescent pregnancy. In fact, most studies comparing pregnant adolescents to nonpregnant peers find no psychological differences. It is likely that pregnant adolescents are too heterogeneous to show predictable differences when compared with nonpregnant adolescents. Therefore, it is useful to identify subgroups of pregnant adolescents that are relatively psychologically or attitudinally homogeneous. Identification of subgroups manifesting meaningful psychological homogeneity could have implications for targeted preventive interventions.

One of the more clinically relevant classifications compiles adolescents' stated and inferred reasons for becoming pregnant into three categories: intentional, accidental, and uninformed (or misinformed). This classification seems quite useful because counseling sexually active adolescents often involves discussing the underlying reasons for having sex, identifying the extent to which the adolescent is willing to use contraceptives and, in some cases, identifying reasons for wishing to become pregnant.

Among adolescents who report that they intended to become pregnant, researchers generally delineate two subtypes. The first subtype tends to be influenced by a culture that accepts and may even reward early pregnancy. Interviews with African-American adolescent mothers in a poor section of the Washington DC area revealed that their pregnancies were almost always intended and desired. In this group, early pregnancies were common, and were modeled by mothers, aunts, and peers, and it was generally assured that extended families would help in caring for the children.

The second subtype of adolescents intending to conceive are often motivated to gain respect as an adult, to have someone to nurture and love, or to manipulate others, such as a boyfriend. Within this group, "intentional" does not necessarily mean "desired." In fact, what may be desired is maturity or love, and pregnancy is viewed (consciously or unconsciously) as a means to that end.

Although intentional adolescent pregnancies undoubtedly occur, the issue of intention is methodologically complicated because reports of intentionality are usually collected after the pregnancy has occurred. An unintended, unwanted conception may be increasingly perceived as "desired" and "intended" as the pregnancy continues. It is likely that such an attribution is commonly made among adolescents who choose to deliver and parent their infants, because even though an adolescent may not have wanted to conceive, continuing to believe that a pregnancy was not intended may imply that the child is not desired.

The second and most common category of pregnant adolescents is composed of those who report that their pregnancy was accidental. These adolescents tend to understand the proper way to use contraception, but do so haphazardly or take risks and do not use contraception at all. Actual contraceptive failure accounts for an extremely small proportion of accidental pregnancies.

The third category of pregnant adolescents are those who are considered to be uninformed (or misinformed). Pregnancy is thought to have been avoidable if proper contraceptive information had been provided. Research from other developed countries shows that even young sexually active teenagers can successfully avoid pregnancy if they are given appropriate information and not left to seek information on their own. If adolescents lack accurate information, they cannot be expected to use contraception reliably. Furthermore, even among adolescents who are somewhat knowledgeable, their sophistication may be limited. Adolescents are not often likely to question the extent of their knowledge, and are more likely to act on their subjective (often inaccurate) beliefs about the probability of becoming pregnant. Most adolescents, even those who are fairly sophisticated, may benefit from appropriate information about contraception.

Implications for Prevention

Several findings from the cross-cultural study and from the studies of psychological factors have implications for the prevention of adolescent pregnancy, although some factors such as American poverty are not easily modified. However, two direct and readily implemented changes are recommended: more extensive education about sexuality and contraception, and an increase in the ease with which adolescents can obtain contraception. In addition, programs designed to enhance adolescents' life options may give young women the incentive to delay pregnancy.

Programs designed to provide education about sexuality and contraception not only provide information, but also provide an opportunity for adolescents to reflect on their attitudes toward sexuality. For example, many adolescents delay the use of contraception for about six months after they begin having intercourse, either because they do not have accurate knowledge about reproduction or contraception, or because they cannot accept that they are engaging in something that they have been taught was wrong. Educational interventions might ameliorate these circumstances. A careful study of a comprehensive school-based program in Baltimore showed that providing education about sexuality and contraception was associated with postponement of first intercourse and higher contraceptive use. This finding is corroborated by studies indicating that adolescents who have had sex education are no more likely, and sometimes less likely, to initiate sexual activity than those adolescents who have not had sex education.

Three types of community-based programs in the United States have been designed to increase contraceptive availability. First, family planning clinics provide reasonably priced contraceptives, among other services. It has been found that clinics are used more frequently if they advertise and provide outreach services, such as community education programs. Second, school-based clinics, unlike family planning clinics, are not explicitly designed to provide contraception, although they can offer those services, along with sex education. Third, condom-distribution programs, usually arranged by family planning providers and public health organizations, choose locations ranging from emergency rooms to video arcades, and simply make condoms available. These programs often target young men. Although it is difficult to control for extraneous variables in community studies, some evidence suggests that condom-distribution programs may be associated with more condom use and lower adolescent birth rates in targeted areas. It deserves restating that there is no evidence that heightened contraceptive availability increases adolescent sexual activity.

Programs that enhance life options have been designed to target psychological factors that may aid in the prevention of adolescent pregnancy. These programs are based on the assumption that some adolescent pregnancies can be prevented if young women are instilled with a sense of self-worth and can understand the value of delaying motherhood in order to pursue educational and career opportunities. Examples of these programs are role modeling and mentoring programs, programs to improve school performance, and youth employment programs. Theoretically, these programs seem useful in preventing adolescent pregnancy, but studies have not evaluated their efficacy.

Summary

Most efforts to prevent adolescent pregnancy are community based. Professionals who work with adolescents should be familiar with family planning and school-based clinics, and with other agencies that provide sex education and contraception. Professionals should convey this information to adolescents in a way that makes these services seem accessible, for example, by giving phone numbers of free clinics and telling them that appointments are easy to make. The fear that sex education and contraceptive availability will encourage adolescent sexual behavior is clearly unfounded and the possibility that such interventions may prevent some young women from becoming pregnant and also prevent HIV and other STD infection cannot be overemphasized. Community based programs to prevent adolescent pregnancy are likely to be effective, but school based programs may reach more adolescents and thus be even more effective.

Robin MacFarlane, Ph.D., is a second year intern in clinical psychology at the Westchester Division of New York Hospital-Cornell Medical Center. This article is part of a larger chapter (with references for the summarized research) appearing in O'Hara, M.W., Reiter, R.C., Johnson, S.R., Milburn, A., & Engeldinger, J. (Eds.). (1995), Psychological Aspects of Women's Reproductive Health. New York: Springer.

Copyright 1997, Integrated Research Services, Inc.