How Do We Reduce Teen Pregnancy in the U.S.?

What we’re doing right, what could still use improvement—and what old assumptions could use retooling

A&Q is a special series that inverts the classic Q&A, taking some of the most frequently posed solutions to pressing matters of policy and exploring their complexity.

Here’s the good news: Teen pregnancy has been on the decline in the United States since its peak in 1991. In 2010, teen pregnancy rates were 44 percent lower than in 1991.

The bad news is twofold. One, the U.S. still has more pregnant teens than most other developed countries. The most recent data from the World Bank has the United States at 24 births per 1,000 women aged 15-to-19. The European Union, on average, is at 11. Canada’s at 10. Japan’s at 4.

And two, it’s not totally clear why the teen pregnancy rate is going down. As the Guttmacher Institute points out in a 2014 report, it pretty much has to be less sex, more contraceptives, or a combination thereof, but “the evidence, however, is much murkier when it comes to deciphering the social, cultural and economic factors affecting teens’ sexual behaviors and contraceptive use patterns.”

If we want to keep the rate declining (and we should: Teen pregnancy is associated with a higher likelihood of illness and death for both the child and mother), it would help to know what we’re doing right—and what could still be improved. And that means questioning some assumptions about both the nature of the problem, and how to fix it.

ANSWER

Teens these days are having sex too young and too much—they’re not prepared and then they get pregnant.

QUESTION

Are you sure you’re not just thinking of Secret Life of the American Teenager? Despite all the sex on teen TV shows, and the hand-wringing over Tinder and “hookup culture,” teenagers are actually having less sex than they were in earlier decades. (And when they do have sex, it’s most likely to be voluntary, with a steady partner, and using contraception.)

Between 2011 and 2013, 47 percent of males and 44 percent of females between 15 and 19 years old reported having had sex. In 1988, 60 percent of males and 51 percent of females in that age group had had sex.

Females and Males Aged 15 to 19 Who Have Had Sex, Over Time

Centers for Disease Control and Prevention

ANSWER

That’s a relief. After all, the best way to prevent pregnancy is just not to have sex.

QUESTION

Okay, that may be true at the most basic mechanical level (if we’re only talking about heterosexual vaginal sex), but if some teens are going have sex anyway (and they are) shouldn’t they be informed?

Despite the fact that it’s been shown time and time again that abstinence-only sex education does not keep teens from having sex, the idea persists that “just say no” is the best thing to tell them. According to the Guttmacher Institute, 37 states legally require teachers to provide information on abstinence, with 25 of them requiring it to be “stressed.”

Research shows that young people who take “virginity pledges” on the whole have the same rates of sexually transmitted infections as non-pledgers, even if some of them do end up waiting until marriage to have sex. That may be because, as another study shows, pledgers who broke their pledge were less likely to use contraception the first time they had sex than their peers. And as you may know, depending on what kind of sex ed you had, that leads to not just STIs, but also to pregnancy.

A comprehensive analysis from 2011 of “all available state data” on sex ed programs in the U.S. found that higher emphasis on abstinence in a state was correlated with higher rates of teen pregnancy and teen birth. That is, stressing abstinence until marriage was worse than promoting abstinence while also teaching about STIs and contraception, which was worse than covering abstinence as part of a “medically accurate” curriculum. (Also, if the outcome you really want most of all is for teens not to have sex, teaching them about contraception and STDs does not make them more likely to do it, for the record.)

ANSWER

So comprehensive sex education is better than abstinence-only sex ed.

QUESTION

Does anyone even know what “comprehensive” means, though? Comprehensive sex ed is often referred to as though it’s the antonym of abstinence-only, but “in reality, programs do not fall neatly into one of these two groups,” according to the National Campaign to Prevent Teen and Unplanned Pregnancy. “Rather, they exist along a continuum, which makes some of them difficult to classify.”

The Sexuality Information and Education Council of the United States defines “comprehensive sex education” as providing “evidence-based, medically accurate, and developmentally appropriate sexual health information to address the physical, mental, emotional, and social dimensions of human sexuality for all young people.”

So it’s definitely better to provide information on contraception and STIs, as opposed to not doing that, but there’s a wide variety of curriculums that could be considered “comprehensive” under this definition. Surely not all are created equal. There is some recent research that finds programs are more successful if they go beyond the medical aspects of safe sex to talk about the relationship contexts sex happens in. Programs that discuss gender inequality and power dynamics in relationships have been found to be more effective at reducing pregnancy and STIs.

ANSWER

Okay, but we’re doing pretty well. Teens are using birth control! (Seventy-nine percent of females and 84 percent of males.) That’s good, and it’s been increasing over the past few decades, and in fact The Guttmacher Institute, which you seem to love to reference, says it’s 86 percent of the reason why teen pregnancy rates are falling.

QUESTION

Yes, but are teens using the best kind of birth control? They’re not, mostly. Not to be a downer or belittle the progress that has happened because it is heartening! Truly.

Using condoms is good. Access to hormonal birth control pills is good. But long-acting reversible contraception (LARC) like intrauterine devices (IUDs) and hormonal implants has in recent years been crowned the queen of birth control—the most effective, the easiest to use consistently (because you just stick it in there and leave it!), and safe. Even for adolescents—the American Academy of Pediatrics has recommended them.

Except adolescents aren’t really using them. Just 7.1 percent of 15-to-19-year-olds chose LARC methods in 2013. This is a notable increase from the 0.5 percent who were using them in 2005 but still—less than 10 percent. The U.S. has historically lagged way behind other developed countries in adopting LARCs. For teens, part of the problem may be that pediatricians are often not trained in how to insert them, and a lot of adolescents still see pediatricians, as Kaiser Health News reported last year. There’s also the specter of the Dalkon Shield, a disaster of an IUD from the 1970s, which may still be making some skittish about complications that could come with IUDs, even though modern versions are much safer.

There is a very strong connection between IUD use and less teen pregnancy—after a six-year program in Colorado that gave free IUDs and implants to low-income teens and young adults (they cost $800 to $900 without a discount), unintended pregnancy rates in the state dropped by 48 percent. Lawmakers in the state recently cut funding for this program, though it was saved by $2 million in private donations.

So expanding access to LARC methods appears to be a good way to combat teen pregnancy, but with all the factors at play, no one thing is going to be the be-all, end-all solution. The World Health Organization, in a review of interventions intended to reduce teen pregnancy, concluded that “single interventions were not found to be effective.” But “combined interventions (such as educational and contraceptive promotion) can play a key role in reducing unintended pregnancies among adolescents.” To continue to make real progress on this problem will require having fingers on many different sliders.

* * *

Further complicating matters are some issues adjacent to teen pregnancy that raise thought-provoking questions of their own:

There’s a gap between teen pregnancy and teen birth, and that gap is filled by abortions. How should we think about abortion when it comes to teen mothers? Many of the states that promote abstinence only sex ed are also very restrictive when it comes to abortions—does this mean more teen mothers in those states?

Safe sex isn’t only about preventing pregnancy. How can sex ed teach teens about safety around oral and anal sex, and how can it be inclusive to LGBT relationships?

Solving the problem of teen pregnancy is not just about prevention. Ultimately, some teens are going to get pregnant. And they tend to face poor socioeconomic outcomes when they do. What can governments, schools, and non-profits do to support them?