Adolescent Pregnancy Prevention Highlights From a Citywide Effort

LOWERING THE ADOLESCENT BIRTHRATE is one of the Centers for Disease Control and Prevention’s 10 “winnable” battles and Milwaukee is leading the way in the fight with a successful community-based pregnancy prevention program.

OPEN A GOSSIP MAGAZINE or turn on the television and you are more likely than ever to see some mention or portrayal of an adolescent mom. For the past several years, adolescent pregnancy has received much press with top billing on ABC’s drama “Secret Life of the American Teenager” and the hit MTV reality shows “16 and Pregnant” and “Teen Mom.” And the media has been at times obsessed with famous young moms such as Jamie Lynn Spears and Bristol Palin. The hype has inspired editorials, articles, and even research examining whether all the attention glamorizes adolescent parenthood and encourages adolescents to have babies or whether, in the end, it helps prevent adolescent pregnancy by encouraging young people to think about the challenges.

It is probably a little bit of both. Adolescents pick up plenty from media. In one study, those who watched the highest levels of sexual content on television (in the 90th percentile of the adolescents surveyed) were twice as likely to become pregnant as those who watched the least sexually loaded shows (in the 10th percentile of the adolescents surveyed).¹ At the same time, young people say that watching a television character they like deal with pregnancy makes them think more about their own risk, and that shows such as “16 and Pregnant” help them better understand the challenges of adolescent parenting.²

In fact, despite the uptick in media depictions of adolescent parenthood, the adolescent birthrate in the United States is the lowest in nearly seven decades of record keeping. A preliminary report from 2010 estimates the adolescent birthrate at 17.3 births per 1000 persons aged 15 to 17 years, a decline of 45% since 1991.³

Although the US rate has declined steadily for 17 out of the past 19 years, it is still the highest among industrialized nations: one and a half times higher than Great Britain, three times higher than Canada, seven times higher than Denmark and Sweden, and eight times higher than Japan.⁴ In addition, within the United States, adolescent birthrates vary depending on race/ethnicity, socioeconomic status, and geography. For example, the rate is 114 per 1000 among Hispanic adolescents in Mississippi and is 8.5 per 1000 among White adolescents in New Jersey.³ Therefore, lowering the adolescent birthrate even further is a priority across the country. In fact, it is one of 10 “winnable” public health battles singled out by the Centers for Disease Control and Prevention (CDC).⁵ And, in 2010, President Obama initiated the “President’s Teen Pregnancy Prevention Initiative,” funding nine adolescent pregnancy prevention programs around the country.

Even before the president’s initiative, the city of Milwaukee, Wisconsin, made adolescent pregnancy prevention a top priority. In 2008, with birthrates among 15- to 17-year-old adolescents high above the national average—47 births per 1000 compared with 22.1 births per 1000 nationally—the United Way of Greater Milwaukee set a goal to reduce the city’s birthrate among this subset of adolescents by 46% by 2015. Although the program aspires to lower birthrates for all adolescents, it centered attention on this subset of adolescents because they would receive the most immediate and intensive intervention during the program’s first several years and would be the group that would best represent whether the interventions worked. Two years into a comprehensive, evidence-based program, the birthrate among this population dropped 24% to 35.68 per 1000 in 2010,⁶ more than halfway toward the goal.

The National Campaign to Prevent Teen and Unplanned Pregnancy calls Milwaukee’s program a model for the nation.⁷ It is a prolonged, coordinated effort that involves the whole community, including city officials, business leaders, schools, and health services. And it uses evidence-based interventions aimed at distinct groups, including adolescents, their parents, and specific ethnic groups (see Sidebar).

For Milwaukee and the rest of the country, reducing adolescent pregnancy rates is not only a winnable battle, as the CDC proposes, but it is also a battle worth winning. It dramatically increases the chance that a girl will finish high school, improves adolescent health, boosts adolescents’ lifetime earning power, and decreases the tax burden on everyone.¹²

PAYING THE PRICE OF PREGNANCY

Social and behavioral factors such as poverty status, early sexual debut, low contraception use, and history of physical abuse and sexual victimization contribute to adolescent birthrates.¹³ In 2005 the United Way of Greater Milwaukee concluded that Milwaukee adolescents are particularly vulnerable because of these factors.⁶

Milwaukee's Adolescent Pregnancy Prevention Program Elements.

The adolescent pregnancy prevention effort in Milwaukee, led by the United Way of Greater Milwaukee, targets all aspects of adolescent pregnancy with a multifaceted approach supported by research on successful prevention programs.⁸

Program elements include:

Providing a comprehensive, evidence-based human development and sexuality curriculum in all grades, for all students.

The Milwaukee Public Schools, with input from educators, parents, and experts, created an age-appropriate, science-based curriculum for use in all public schools, ensuring that the 30% of Milwaukee students who move between schools each year receive consistent health education. United Way then awarded a grant to the schools to train teachers to deliver the program with fidelity. The curriculum increases students’ understanding about healthy relationships, delays onset of sexual behaviors, and increases consistent use of contraception when adolescents engage in sexual activity.⁶

Providing evidence-based prevention programming outside school for girls and boys.

The United Way of Greater Milwaukee funds community-based organizations to implement two well-established and evidence-based curricula⁸ aimed at difficult-to-reach populations: Making Proud Choices! teaches adolescents how to reduce their risk of sexually transmitted infections, including HIV, and pregnancy by choosing abstinence or condoms. Studies show, particularly among African American youths in the program, increased condom use and decreased frequency of unprotected sexual intercourse for as long as a year.^9,10 ¡Cuidate!, a version of Making Proud Choices! adapted for Latino youths, also teaches responsible health behaviors.¹¹

Including parents in prevention programming.

Parents play a critical role in adolescents’ decision-making.² Forty-six percent of adolescents say that their parents are the biggest influence on their decisions about sexual activity and 80% say that it would be much easier to delay sexual activity and avoid adolescent pregnancy if they could have open, honest conversations about these topics with their parents. To encourage parental–adolescent communication, the Milwaukee program created a family communications toolkit called Let’s Talk! The kit includes step-by-step suggestions for communicating with adolescents about sexual activity. By May 2011, more than 7000 Milwaukee families received toolkits. Parents are involved with the Milwaukee Teen Pregnancy Prevention Oversight Committee and, through partnerships with the Milwaukee faith community, have participated in parent and guardian information sessions about faith-based programs to encourage healthy decision-making and self-respect.

Supporting greater access to comprehensive reproductive health services.

The United Way of Greater Milwaukee, along with support and resources from the Adolescent Sexual Health Coalition of Milwaukee, local pharmacies, Milwaukee Adolescent Health Services, Milwaukee Health Department, the Baby Can Wait Web site, and Planned Parenthood, has increased access to contraceptive services, sexually transmitted disease screening, pregnancy testing, physical examinations, and family planning services for adolescents.

Creating a mixed-media campaign that uses posters, advertising, and news coverage to reach adolescents, their parents, local businesses, and the community at large.

Throughout Milwaukee, residents can see dynamic, hard-hitting messages at bus stops, on billboards, on bathroom walls, on Facebook, and on public buses. In addition, the Teen Pregnancy Prevention Oversight Committee cochair is the publisher of the local newspaper, the Milwaukee Journal-Sentinel, which has published articles that feature the issue. Because of the campaign, more adolescents in Milwaukee maintain negative perceptions about becoming pregnant and more residents and businesses view adolescent pregnancy as a social problem that affects the entire community.⁶

For example, Milwaukee is the fourth poorest city in the United States,¹⁴ with more than 40% of children living below the poverty line. In addition, according to the Youth Risk Behavior Survey, Milwaukee high-school students are far more likely to report risky sexual behavior compared with national estimates: They are twice as likely to initiate sexual activity before they are aged 13 years; they are nearly twice as likely to have ever had sexual intercourse and to have had four or more sexual partners; they are close to 50% more likely to have been physically hurt by a boyfriend or girlfriend; and they are more than 40% more likely to have been forced verbally or physically to participate in sexual activity.¹⁵ As a result, Milwaukee has an adolescent pregnancy rate double the national average, putting it among the top-10 cities in the United States with the highest adolescent birthrate, along with Denver, Colorado; Dallas, Texas; Memphis, Tennessee; and Baltimore, Maryland.

The social and economic impacts of adolescent pregnancy on these cities can be devastating. In 2008, adolescent pregnancies cost the United States an estimated $10.9 billion from increased welfare and Medicaid payments, incarcerations, foster care, and lost tax revenue.¹⁶ In Milwaukee alone, a single adolescent birth costs an estimated $79 320 per year in health care and other services.

Added to the direct expenses of caring for adolescent mothers and their babies are the costs to society of an uneducated workforce. Only half of adolescent mothers in Milwaukee and throughout the country receive a high-school diploma by age 22 years, compared with 89% of girls who do not become adolescent mothers. Those numbers are worse for girls who have a child before they are aged 18 years: only 38% earned a high-school diploma by age 22 years, compared with 60% of girls who had their first child at age 18 or 19 years.¹⁷

Whether a child’s mother receives a high-school diploma or general equivalency diploma is one of three factors that increase the likelihood that a child will live in poverty, which in turn puts children at risk for becoming adolescent parents themselves, according to the National Campaign to Prevent Teen and Unplanned Pregnancy. Along with an increased likelihood of growing up in poverty and becoming adolescent parents, the children of adolescent mothers are more likely to be underweight at birth, to be unprepared for kindergarten, to have behavioral problems and chronic medical conditions, to be incarcerated during adolescence, to drop out of high school, and to be unemployed or underemployed as adults.¹⁸

A COMMITMENT TO CHANGE

The social and economic consequences of adolescent pregnancy have, in recent years, motivated many states and cities to implement comprehensive adolescent pregnancy prevention programs. The President’s Teen Pregnancy Prevention Initiative is spending $114.5 million over five years to demonstrate the effectiveness of communitywide programs.¹⁹ In 2010, the initiative funded nine state- and community-based organizations in communities such as West Philadelphia, Pennsylvania; Hartford, Connecticut; and Mobile County, Alabama, to implement innovative programs focused on reducing adolescent pregnancy and birthrates, particularly among African American and Latino or Hispanic adolescents. The goal is to reduce adolescent birthrates by 10% by 2015. By then, Milwaukee expects to have reached its goal of reducing adolescent birthrates by 46% with a sustained program that can be a model for other communities.

Like the president’s initiative, Milwaukee’s effort is based on the idea that prevention efforts are more likely to succeed if they are evidence-based and sustained over time.^20,21 The United Way of Greater Milwaukee began by creating partnerships with state and city governments, the Milwaukee faith community, Milwaukee Public Schools, and local media. Maintaining those partnerships over the long term has been key to the success of the program, according to the program’s coordinator, Nicole Angresano, MPH. They built a large coalition and most of the members have remained committed to the program, including the two cochairs who have provided consistent leadership.

“We said early on that we need to make a commitment, internally and publicly, that the initiative will be sustained even beyond our end-goal of lowering the adolescent pregnancy rate by 46 percent,” said Angresano (oral communication, January 23, 2012). “In fact, it is not an end-goal, it is our first goal. Even when we get to a 46 percent drop, that is still too many kids having babies. We will continue to press and not become self-congratulatory.”

CREATING AN EVIDENCE-BASED INTERVENTION

The Milwaukee initiative includes all the components of a successful adolescent pregnancy prevention program, including a public awareness campaign, support of school-based health clinics, a parent-involvement component, and a comprehensive health and sexuality education component.⁸

By identifying the goals and desired outcomes of its prevention effort, and evaluating the scope of the city’s problems, the United Way of Greater Milwaukee followed many of the steps laid out by the RAND Corporation in its “Getting to Outcomes” toolkit.²² Supported by the CDC and based on years of research, the toolkit is designed to help communities plan, implement, and evaluate all kinds of community-based prevention programs. The CDC adapted the toolkit into a guide called “10 Steps to Promoting Science-Based Approaches to Teen Pregnancy Prevention Using Getting to Outcomes.”²³ This guide can be used to create and evaluate adolescent pregnancy prevention programs.

Step 3 in the CDC’s toolkit is: “Find existing programs and best practices worth focusing on.” To do that, the Milwaukee program relied heavily on What Works. Curriculum-Based Programs That Prevent Teen Pregnancy.²¹ The booklet, published by the National Campaign to Prevent Teen and Unplanned Pregnancy, divides effective programs into five broad categories: curriculum-based education, service learning, youth development, parent programs, and communitywide programming (see Sidebar).

The coalition acknowledged the need to pay particular attention to Milwaukee’s African American and Latino communities by choosing targeted health and sexuality curricula. As in the rest of the country, these populations have higher than average rates of pregnancy. Statistics among adolescent Latinos are especially stark. The National Campaign to Prevent Teen and Unplanned Pregnancy estimates that, nationally, more than 50% of Latinas become pregnant as adolescents, similar to the rate for Latinas in Milwaukee.²⁵ Therefore, the United Way of Greater Milwaukee formed the Latino Community Task Force in April 2011, to formulate better strategies to target this group. The task force focuses on the role of family and religion in sexual decision–making practices to enhance education and intervention efforts.

Despite the need to focus more acutely on target groups, Milwaukee’s efforts are paying off with large declines in the birthrate among all adolescents aged 15 to 17 years during the five years the initiative has been operating. Given that Milwaukee’s poverty level increased significantly, the decrease in the adolescent birthrate is noteworthy.

Milwaukee is not the only city making strides in adolescent pregnancy prevention. Across the country, cities and states are redoubling their efforts to reduce adolescent birthrates. For example, the South Carolina Campaign to Prevent Teen Pregnancy has created a comprehensive adolescent pregnancy prevention program that includes a goal to strengthen science-based approaches for adolescent pregnancy prevention in schools. It also provides training and technical assistance to local organizations working around the state in schools, community organizations, and after-school programs. In Virginia, the Department of Health and Human Services created a program designed to ensure that children transitioning out of foster care have the skills and knowledge they need to develop healthy sexual relationships.

The ultimate goal for all these programs is to significantly reduce adolescent birthrates. Milwaukee believes that its program is well on the way to surpassing its goals by making adolescent pregnancy prevention a top priority for the entire community. programs. The United Way of Greater Milwaukee focused on education, parents, and community.