AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
CINDY COSTELLO: Well, this is great. We weren't sure, the last, last day at 9:00 in the morning, how many diehards would turn out. And we're delighted to have you all here. Pat and I are going to talk today about some research that was undertaken. Dr. Lorraine Klearman produced the report for the National Campaign to Prevent Teen Pregnancy and the Healthy Teen Network called Another Chance Preventing Additional Births to Teen Mothers. You have the executive summary of that report here and can get the full report from either of our organizations.
I also wanted to mention that at the back table the PowerPoint is there, as well as a Science Says on older teens that the national campaign prepared through its CDC funded project. And I'm delighted to be here, and I'm delighted to have the opportunity to present with Pat, who is a close colleague, and we work a lot together across the two organizations.
We're sort of going to go back and forth, the two of us, in this presentation. This presentation covers four areas. I want to tell you a little bit about the National Campaign to Prevent Teen Pregnancy, and Pat will do the same thing about her organization, Healthy Teen Network, formerly NOAPP. We wanted to give a brief overview of teen pregnancy in the U.S. and where second and higher order higher births fit into the child birth picture for teen mothers.
And, finally, we want to present the major findings and implications from this report that was prepared by Dr. Lorraine Klearman, one of the foremost experts in this field of preventing additional births among teen mothers.
How many of you have heard of the National Campaign to Prevent Teen Pregnancy? The campaign has worked fairly closely with AMCHP over the years. Our missions are very closely aligned. Our mission is to improve the well‑being of children, youth and families by preventing teen pregnancy. And from the outset, the campaign has approached teen pregnancy prevention as both a health issue and economic security issue, for all the reasons that are familiar, I'm sure, to all of you, that when a teen has a child, her probability and the probability of the child of living a fair number of years in poverty is fairly high. The campaign's goal, when it was established, was to reduce the rate of teen pregnancy in the United States, to have the nation reduce the rate of teen pregnancy in the United States by a third, between 1996 and 2005; and due to a number of factors, including the extensive efforts of many state and local programs, it looks like the nation will meet this goal.
The strategy of the National Campaign to Prevent Teen Pregnancy is multi‑fold. All of our work is based on research, and from the outset we've worked with an effective programs and research task force made up of social scientists to prepare reports such as this Another Chance report that was released with Healthy Teen Network, so that we always know that when we're targeting our efforts they're based on what's going on currently with teens, the role of parents, which programs are effective, which aren't and whatnot.
We also have felt from the outset that if teen pregnancy rates are going to decline and continue to decline, that we need to work both with our traditional partners, those who, as our director Sara Brown says, wake up every day and ask themselves what am I going to do today in working with teens to discourage early sex and teen pregnancy and contraceptive use, we also believe it's very important to work with a broad array of opinion leaders. We do a lot of work with Hollywood script writers to interject positive messages around sexual behavior for teens.
Like most organizations that work on this issue, we have strong teen involvement through a youth leadership team as well as through what we call the Youth On‑line Network, where thousands of teens interact with us, and we have the opportunity to ask them what they're thinking about particular issues.
Particularly, given the political climate of the last decade or so, it's been very important, we believe, to try to find common ground and work with colleagues on both sides of the political aisle. And, of course, our primary audience for most of the research products that we put out, the public service announcements and whatnot, is state and local programs and national organizations like yours that represent practitioners across the country.
I'll turn the floor over to my colleague, Pat.
PATRICIA PALUZZI: We'll do a little bit of jumping up and down, but not too much. Good morning. Thank you for coming showing up this morning. The National Organization on Adolescent Pregnancy Prevention, now Healthy Teen Network, is a 25‑year‑old membership organization that was formed originally by folks working with pregnant and parenting teens, it was back in the days when it had two Ps as opposed to three Ps it had until very recently. It was formed because the providers working in those arenas felt they wanted to have a national voice, an umbrella organization that would help them in their networking and research efforts. That's what the organization has done for the past 25 years.
The reason behind the name change, because I know people always wonder about those things, is we did a lot of work with a marketing and branding firm last year, spending a lot of time doing the sort of analysis of the field, where the different nationals are, where our work sort of fits in, what is our particular niche, and what should we be doing to kind of remain viable, should we remain viable, et cetera.
And the name change is one of the things that emerged from that. And just for those who have any interest in marketing, the reason for the name change is two‑fold: One, it's shorter and easy to remember, because nobody could ever keep those three Ps straight, including like board and staff. The other is it's outcome‑based as opposed to just defining the issue. It talks about the outcomes, and that's where people are today in thinking about names.
So I hope you like it. It's always a risk when you change a name. So we hope you can all embrace our new name.
That said, the mission and the vision of the organization have remained the same, and the vision of our organization is that all adolescents will make responsible decisions about sexuality, pregnancy and parenting; and we believe, if they're given age appropriate, culturally appropriate and medically sound, scientifically based information, that they're able to do so.
Our mission, because we're a membership organization, then, is to provide the leadership, education, training, information, advocacy, resources and support to individuals and organizations in the fields of pregnancy, parenting and pregnancy prevention.
We work across three major topic areas right now, I would say, or focus areas. Young families remains a focus area. So pregnant and parenting teens, the mothers, the fathers, and the children all remain a population that we have concern about. We're one of I think the only national that works somewhat in this area along with the prevention area.
We also work in terms of prevention, besides we work a lot with the more complex issues of prevention. Historically some of the products that we've done and will continue to do are exploring like the intersection of violence and teen sexual behavior and teen pregnancy prevention, issues affecting some of your more disenfranchised populations, issues areas disparity, et cetera. The other thing that we focus on is promoting science‑based practice and policy in the field, and we do this a lot through working with our state and local coalitions, as well as our general membership.
So our strategic approach is to working on all of those issues are we work in the area of research and evaluation, which, for us, is the kind of research that is sort of building knowledge in the field, not too dissimilar to what the campaign does. Not in thinking about academic type research, but the kind of very applied stuff that folks can use such as the Klearman report that we're talking about today.
Policy and advocacy. Again, we believe that because we work on a tiered approach working through the state and local coalitions, and our members to finally get down to the local level where teens and their kids are impacted, we do a lot of our policy and advocacy work on the state and local level. Information dissemination is not dissimilar to AMCHP. It's all of the products and conferences and websites and list serves and things that member organizations do to try to keep their members informed and supported. And training and technical assistance are just the different areas where we've developed some curricula and expertise, a lot of which have emerged recently through the CDC Cooperative Agreement.
The CDC Cooperative Agreement was funded, of course, by the Centers for Disease Prevention and Control, and the goal of this agreement is to enhance the ability of state and local coalitions or organizations to incorporate science‑based approaches into their teen pregnancy prevention efforts. Again, recognizing the work on the three levels that will help to make change at the state and local level, that support from the nationals to do that is critical.
And so they funded three national organizations, and at this point five local coalitions in order to do this work. Advocates for Youth, the National Campaign, and now Healthy Teen Network are the three national organizations that were funded in this effort. The five state level coalitions were Arizona , Massachusetts , Minnesota , South Carolina and North Carolina .
And all three of the national organizations have approached their work slightly differently. Cindy will talk about what the campaign has done. Healthy Teen Network has worked on the two levels of trying to achieve both our membership as well as our coalition efforts, and I think your slide comes first before mine, so I should stop. We have a little moment here.
So plus ‑‑ then Advocates For Youth, to finally say Advocates For Youth, the third organization, is also doing a lot of capacity building with the state and local coalitions. They focused more on the area of getting your board to be more effective, how to do effective fund‑raising, those sorts of activities.
CINDY COSTELLO: I just wanted to say a few things about our CDC Cooperative Agreement, which, as Pat mentioned, is a collaboration across eight organizations, so that you can know about the resources that we have available on our website. Much in line with how the campaign has worked since its inception, we have benefited from having support from CDC, so that we have been able to prepare a number of reports and what we're calling Science Says issues briefs, one of which is in the back there on older teens. All of which are available and can be downloaded for free from our website, www.teenpregnancy.org. And our goals here are, the first and foremost, to make materials on effective programs and good, solid research on what teens are doing in terms of their sexual behavior, attitudes available to the field.
We've just been delighted. I think as of last month there's something like 300,000 of these documents have been distributed and downloaded. They're very, very popular. Some of our reports summarize effective programs. What we often hear from the field is that they need to know more specifically, people need to know more specifically not just that a program such as reducing the risk has been shown to be effective, but what does that mean. What was the curriculum? What was the balance between the message around delaying sex and using contraception and perhaps, most importantly, who is it effective with and for how long.
This whole area of effective programs that we're all rightly being encouraged so strongly to promote is, as one of my friends say, sometimes you feel like you're sculpting fog. There's very few programs that work for a very long time and with a number of different populations. And our publications really zero in on what programs work in after school settings, what work for middle school kids, what work for delaying first sex. And then we have these Science Says issues briefs, I believe we have 14 of them, that focus on everything from the sexual behavior of older teens, a group that, at least my sense, is often overlooked, but of course that's where most of the pregnancies and births are and their kids don't tend to fare any better than the children of younger teens.
We also put out a very popular Science Says on when and where teens have their first sexual experience. Most people think it's after school. Actually, it's in the evening. Not that after school hours aren't a key issue. We need to keep fighting for those after‑school programs. And be aware, you know, teens tend to have their first sexual experience in their own home or the home of their boyfriend or girlfriend or friend.
So check out the website. I think there are a lot of tools there you might find useful. And the issue that we're talking about today, Another Chance, preventing additional births, we have a Science Says based on this report on our website that is downloadable for free.
PATRICIA PALUZZI: And the work that Healthy Teen Network has been doing through this initiative is two‑tier. Again, because we're a membership organization, that is, the expectation from CDC is that we would impact on those two levels across our membership as well as across the state and local coalitions. And, of course, you can't expect to do the same things and have the same impact with both of those populations. So for the general membership, our objective was to improve their knowledge and attitudes regarding science‑based practice, not attempting to change behaviors, or we would like to change behaviors but not being held to demonstrating a change in behaviors.
The kinds of activities that we've done there, we, in our written publications, we have put more of an emphasis on research in the quarterly newsletter that we've produced. We had a research track at the conference last year for the first time. We began doing a research award as part of the awards that we generally give on an annual basis. And doing more on our list serve in terms of steering people towards studies. So trying to get the general membership hearing about science‑based practice and getting exposed to the idea of using science‑based practice, and that's sort of why, and we assess our success through an annual membership survey at the conference.
Through the state and local coalitions, our objective there was to actually promote science‑based practice through the building of these coalitions, capacity. And this we've partnered with ETR Associates, if you're familiar, a large research training group out of California and have developed a series of modules on the use of a logic model, sort of Basic Evaluation 101, using data to improve programming and evaluating the effectiveness of your coalition are four that we designed and delivered with them last year, over the past two years, and we're continuing. This is the third and final year of this CDC initiative. And so the audience has primarily been the five coalitions that were also supported because, of course, they have the capacity to be able to receive the training. Generally they pull together folks from their region and we come in and deliver their training and try and help. So then offer them continuing technical support to be able to then work on the local level with their folks and their regions to promote practice.
The other things we have done is to really provide some opportunities for networking among leadership. We have a leadership roundtable that we've held in conjunction with Advocates For Youth all three years, where we've brought together the CDC partners as well as the coalition leaders and national campaign, other partners in the project, and have had different sorts of training that will build them as leaders and allow them opportunities to network and discuss around these issues and what kind of things are working and what kind of things they need support with.
All of these projects, to be aware, have an evaluation component. All the national partners and all of the local partners have an evaluation component that's been integrated throughout. So there will be some findings from all of this in terms of how successful this tiered approach and multi‑level approach has been.
CINDY COSTELLO: Now we want to talk a little bit in terms of what's going on in terms of teen pregnancy, trends, child birth trends and where additional births fit into this overall picture. This is probably a familiar slide to many of you in this room. After experiencing a significant increase between around 1970 and 1990, the teen pregnancy rate for girls decreased substantially 28%, between 1990 and 2000, to a record low.
The teen birth rates tend to track in terms of the slope of the trend fairly closely to the teen pregnancy rates, and we see a similar trend: There was a significant increase between 1940 and 1957 in teen birth rates. The birth rate dropped fairly steadily from the '50s to the mid‑80s and increased again between '86 and '91, but the key decade we're zeroing in on here between 1991 and 2003, the birth rate decreased 32.5%.
What we usually see is that the teen birth rate is about half of the teen pregnancy rate. To summarize what's been happening between 1991 and about 2000, the teen pregnancy rates declined 28% from 116 per 1,000 to about 84 per 1,000. As I mentioned, the teen birth rates tracked this decline, declining 31% during this same period.
Now, when we look at teen birth rates among different race and ethnic subgroups, what we see is sort of a good news/bad news picture. We have a decline among all groups between this period, this decade of 1991 and 2002 in terms of teen birth rates, but the highest teen birth rates remain among Hispanics and African American teens.
Some more numbers that show sort of a mixed picture in terms of where the trends are going with teen sexual behavior, when you look at this same decade, the decade between '91 and 2003, the percentage of teens who have ever had sex declined, but some groups have much higher rates of sexual activity than others. 57% of Latino teens report that they've had sexual intercourse versus 47% of teens overall. The percentage of teens having multiple partners is declining, but I think all of us would agree that the closer one gets towards zero, the better, in terms of having multiple partners and the risk both of pregnancy and STDs among adolescents.
Another piece of good news, I guess depending on your perspective, the percentage of teens using condoms has increased over this same period. But one of the issues that we have to be careful about in looking at condom use is what the actual question was of the teens in a particular survey. Teens are asked if they use condoms at first sex, if they use condoms at last sex, and we find, for example, that as boys age, they're less likely to use condoms consistently over their adolescent years. So it's a complicated picture in terms of condom use.
Unfortunately, teens often use condoms in their first sexual experience with a new partner but after they've been going out for a period of time they stop using condoms consistently, a fairly significant percentage of teens do.
And, of course, they're one of the indicators of how far the U.S. still has to go is it still has the highest rate of teen pregnancy in the industrialized world. More than twice as high than a number of countries in Europe .
And, you know, more than one in three teen girls become pregnant at least once before the age of 20, and the recent data shows a slight increase in percent of high school girls who have had sex. That's something we certainly want to watch closely.
Let me now turn to the principal material that we wanted to cover today, the report Another Chance Preventing Additional Births Among Teen Mothers. Why care about subsequent births among teen mothers? As I mentioned, the overall teen birth rates are down. That's good news. But additional births to teen mothers are still disturbingly common. In 2002, the most recent year for which we have data, there were almost 90,000 such births representing one in five of all teen births.
So when you look at all the babies born to teens, one in five are second or higher order births to teen moms. Nearly one in four teen mothers have a second birth before the age of 20. And as I mentioned at the outset, in terms of the picture with older teens, I'm not exactly sure why, I think it has to do with teens, the expectation that teens are out of high school after they're 18, that they're of legal age, for a whole number of different areas. But, in fact, neither the mothers nor the children fare particularly well, when you look at the children of older teen moms. And this is particularly true when it's a second child for the teen mom.
Now, the reasons for additional births, and Pat is much more familiar with this area in terms of really working on the ground than I am, but when Dr. Klearman looked at what some of the research shows, you know, at first blush it's somewhat perplexing because the girls who have a first birth often talk retrospectively about not having realized how it would change their lives, not understanding the care that a baby takes, not realizing that having a child would take them away from their peer network, when some of the motivation in some cases is to have a similar experience as peers who are having babies.
At first blush none of these things would appear to be true for the girls who go on to have a second or third child when they're teens. Some research has shown that girls with a higher risk for closely spaced second births include the younger teen mothers, the girls who have already had a baby before when they're age 16 or younger. African American and Latino teens are more likely to have a second child if they have a first. And not surprisingly, there is a correlation between educational expectations and whether the girl has dropped out of school or not. Lower educational expectations and having dropped out of school are correlated with having a second birth.
Some research has shown that girls with a higher risk for closely spaced second births also include teen moms who had a desire to have their first child. Now, this is a very complicated area, this area of intendedness and unintendedness of pregnancy. It's complex for adult women, and it's doubly so for teen mothers. Teen mothers who live with a boyfriend, spouse or other adult are more likely to go on to have a second child than if they're living with a parent or alone. And this is really interesting in terms of the recent discussion and debates around marriage as well.
What are some of the consequences for teen mothers? Teen mothers who have closely spaced second births are more likely to initiate prenatal care late. They're less likely to complete school, and they're less likely to be working. This is compared to teen moms who have one child during their teenage years when you look at the consequences for children, the children of teen moms, and you compare five‑year‑old children of teen moms who avoided a second birth with five‑year‑old children of teen moms who went on to have a second birth, those only children at five years old are better prepared for school, better behaved and more outgoing and happy. This is in terms of survey research.
I thought I would just mention a book that you all may have seen that I found really quite gripping in terms of case studies of girls who have babies during their teen years and some of whom who go on to have second children. I want to get the title for you. It's based on a case study in (inaudible) Massachusetts a book called Growing Up Fast by Joanna Lippor, and it was just published in November of 2003. And it's five or six profiles of girls in Pittsfield , if you are familiar with the area, I have a sister who lives there, it was a small industrial city that's lots thousands and thousands of jobs as General Electric moved out over the last 20 years. Unemployment is high. And also, somewhat ironically, Pittsfield is the center for a number of drug rehab programs. And what was captured in this book is that there's a fair amount of people staying on in Pittsfield after they've gone through drug rehab programs going back out and using again and these young girls ending up in relationships with young men who have been associated with these drug rehab programs. So there's a number of things going on in this community but not unlike many of our communities across the country.
This case study of Shala I found particularly gripping. It's the one case in the book where a girl had two children. She, herself, was born to parents who were teens when they had her. And Shala had her first child at 16 and her second at 19. She discussed her first pregnancy as having been planned, but of course we know that's a really complicated thorny area for many girls.
She reported that she had no long‑term plans, and she had no role models for the choices that might be available to her in her life. In fact, her dream had been to be a cheerleader for the Dallas Cowboys, do I have the right football team, and that theme just keeps coming up, because that dream was really punctured by the changes that happened in her life. She wanted to keep her boyfriend and wanted to be popular with her peers, who were also having children.
And I think this quote from Shala is so telling: "I definitely think my environment influenced me to get pregnant. When you're around people that are constantly doing something, you'll pick it up. If I'd hung out around with people more school‑oriented and focused on the bigger picture, I don't think I would have gotten pregnant."
We all know, working with and raising teens, kids tend to gravitate toward what they see around them. And she says it more clearly than I ever could. Shala broke up with her first boyfriend and after several years she had another relationship, and she felt that she had missed out on a lot of mothering interactions with her first child. She had gone back to school. She'd been working. And she went on to have a second child. She talks in more mixed terms about whether it was a planned or unplanned pregnancy.
Her grandmother, in fact, is taking care of her children, and Shala is working. She works at Dunkin' Donuts in the Pittsfield area. I think these kinds of portraits graphically depict the life changes for these young girls and the difficulties and challenges in going on to finish one's education and prepare themselves for economic self‑sufficiency and employment over time.
So I will turn it over to Pat at this point to talk a little bit about some of the impacts and what the program evidence shows.
PATRICIA PALUZZI: I want to add, we had Joanna Lippor at our conference in November. And she also has a film and did a discussion with the film, and it was actually really good. So if she comes in your area or you have an opportunity to try and engage her, the film is very interesting. She's given a lot of thought to it and does a good job presenting it. And it was very, very well received at our conference. It was an enjoyable presentation and a very thought‑provoking presentation. As Cindy said, it's an interesting community that sort of represents across lots of, cut across America kind of thing. You get a picture of some of the issues coming on. L‑i‑p‑p‑o‑r. Joanna Lippor. She has, not a publicist, but the person who sets up her stuff. What's the name of that person who does that stuff for you. I can't remember. Manager, simple enough.
If you can't find her, if you e‑mail me I have some cards up here, I'm happy or it's pat@healthyTeenNetwork.org. I'd be happy to get you in touch with her manager, and you can go from there to contact her.
We're going to spend a couple of slides here talking about the maternal and child health impact of teen births because we know we have maternal and child health providers audience here and we know this is a particular interest to you.
Do most of AMCHP, my assumption about most of AMCHP members is that you work with state and local health departments in the areas of maternal and child health, is that a correct assumption? Yes. So most of you are direct providers in clinic areas or managers of providers? No? How many are direct providers? Okay. So most are not, actually. Are most of you managers of clinics? Most are managers. Okay. So you're probably well versed in this as well but we want to take a minute to talk about some of the issues that are particular to teen births and teen moms.
Cindy said teen mothers are less likely to have adequate prenatal care. This is true with their first pregnancies and even more true with second and third pregnancies. And we can all sort of guess some of the reasons for this. If you're hiding the pregnancy, if you are in denial about the pregnancy, if you're not sure where to go because you're not talking to anybody about it. We can see that with the first. And with the second and third, I think it gets a little more mixed. I think they could be busy. It could be difficult to get there. I think that for all women, and I'm a nurse midwife, so I say this from that perspective of having done clinical work for a long time, I think after you do prenatal care, sometimes you think: Now what was that all about and how much of that do I need? If you're not sophisticated enough to sort of get, in your thinking, to get all the value you get out of that, you might think they just took my blood pressure, I don't need to go back for that. I think it's easy to dismiss.
Teen mothers are more likely to have low birth weight infants. Which, of course, we know low birth weight is one of the three major reasons for infant mortality in this country. And the findings, this is true for the first births among teen moms but the findings are less clear for subsequent births among teen moms. The research is mixed that shows sometimes low birth is not common in subsequent pregnancies. I don't know why that is but I'm going to guess at something, which is if you're hiding the first one, you're probably not eating as well because you're trying to stay thin. If you're not as worried about hiding the second one, you just might eat better, even if you're not getting prenatal care, you might just allow yourself to eat a little bit better. Other than that that's just my guess. I don't really know why that might be.
Because clearly there's a link between prenatal care and low birth weight but there's also a huge link with diet and good nutrition. We also know teen mothers are more likely to engage in anything we don't want them to engage in during pregnancy. More likely to smoke cigarettes, more likely not have an adequate diet more, likely not to take their vitamins and have an appropriate weight gain.
We also know that among the children of teen parents, they're more likely to have emergency medical visits, and this could be for two reasons, one, that they're not taking full advantage of preventive care in the way they should and use emergency visits as some of their ways to get child care for their children and/or, and I think it's a mix of both, the children are more likely to be, to get more illness and being treated in emergency settings. We know there are more developmental delays among children of teen parents as well. We know there's a tremendous amount of good work done with early headstart and other programs to help take care of some of this. But we know that education of mom is the strongest predictor for the sort of educational outcome for children as well.
And so with dropping out of high school, teen pregnancy is the number one reason that girls drop out of high school. So you have sort of a set up of girls without the education raising young children, not giving the stimulation and the environment they should and the kids starting out with some delays right off the bat. We also know that pregnant teens are at a greater risk for intimate partner violence and perhaps even death. There were two very, very interesting studies that came out about three years ago now, I guess it is. One was done here in DC and one was done in the state of Maryland , where two different researchers looked at the medical records. ME records, of women who had autopsies. And they particularly were looking then at those who had been diagnosed as death by homicide, and then they looked at those who were pregnant. They did a correlation with early pregnancy. So they could only review records where the uterus had been examined so early pregnancies could be detected. They did show a relationship between pregnancy and homicide. And they showed that relationship was incredibly strong for teens.
It was a statistically significant relationship, and I think the odds were like two to three times greater that teens who were pregnant, teens who were killed were more likely to be pregnant than teens who were not killed. Now does that say that it's at the hand of an intimate partner? No, they couldn't make that claim on the research they did; but you can certainly make some assumptions about it. And we've seen enough in the public press and enough cases, what this did for me because I already worked for a lot of years as a clinician and I had done a lot of work in the area of violence, but you have to ‑‑ when you talk about training people in terms of intimate partner violence, you talk about always screening them alone, never in front of anybody, never make any assumptions about who is with them, that even in terms of giving them the diagnosis of a pregnancy, you know teen moms, teenagers will often have their mom with them or a girlfriend with them and want that person in the room with them. And I think we all have to think really carefully about our protocols around just letting people know about their pregnancy status and are they safe and is this going to be okay when they go home and tell people, who are they going to tell and are they going to be safe when they tell? It's a hugely significant issue for teens that we have to really be mindful of in our clinical work.
And I would say for those of you managers in establishing clinic policies that provide for that kind of privacy and safety assessment.
That's a big aside from our topic, but it's my area of passion. So I always have to go there.
So now we're going to look at the program findings from this study and talk a little bit about those. First of all, just to talk about what the inclusion criteria were for the study: The programs that were included in Klearman's work had to focus on either pregnant or parenting teens. Were conducted in the U.S. only. Used either an experimental or quasi experimental design for the evaluation. Had a sample size of at least 50 in each group. So both the case and control group, as it were. And that the teen mothers were followed for at least 12 months postpartum.
Some caveats about the results of this work: That there were many differences that occurred, leaving comparison difficult. For example, the participants, there was a lot of difference in age and the pregnancy number. For example, in some samples they only had girls who were 18 and younger. And others they went up to age 20. They might have included girls who were having a first‑time birth. Others would have included those who had more than one birth, et cetera. That the programs differed greatly in the length of stay, the length of follow‑up and with the care for teens adding either their first or greater than second pregnancy.
So, again, when you're comparing results you see as we go through these some had results for 12 months, some for 24 months, some for on out to 60 months. Some for only 60 months. And there are a lot of differences in what you know about that, because as Cindy said earlier, we know that all programs have sort of a different impact. Some work really well for the beginning but not the long haul. If you're measuring something only at 60 months you might be missing out shorter term. If you measure only for 12 months you're not really sure what's going to happen past that.
Also on some of these follow the girls and actually provided services postpartum and the others didn't. The evaluation differences such as the outcomes were measured that were measured. Some were looking for repeat pregnancies, some were looking for repeat births; some were looking at birth spacing and whether or not they were the quasi‑experimental design, which is you're comparing to what you think is a similar group as opposed to a randomized trial where randomly having some girls get the intervention and some girls not, which is of course the gold standard in our work; but here you're choosing another population who you think is similar enough to make some comparisons. So we know that has its biases and its shortcomings; and a lot of girls as you can imagine lost to follow‑up. We all know that whether we're researchers or clinicians, how hard it is to keep people engaged, particularly teenagers, for any period of time. They didn't have an adequate description of the programs. We say all of this because whenever you read any kind of report of any research you should know what the shortcomings are of that research.
So I'm going to go through the findings with a bit of detail. In all there were 19 programs that were included in this study. There were six different types of programs that were included. And these were multi‑site programs, and by that I mean that they had multiple sites of the same intervention happening. That some were based in the medical setting. Some were based in schools. There were home visiting programs that were included, contraception‑based, and then there was a host of others that included incentives, second chance homes and a couple of different things that I'll get to toward the end.
The first set that we're going to look at are the multi‑site and there were six of these. These programs had a tendency to emphasize education, employment and self‑sufficiency more than an emphasis on pregnancy prevention per se. This is important to think about as you look at all these programs because we're going to talk about that as a broader issue, the focus of the program and the impact that has on outcomes.
So the programs that they looked at were Project Redirection, Parents Too Soon, and there were two of those, Teenage Parent Welfare Demonstration Program, New Chance and Early Headstart. And I'll give you just a couple lines about each one. Project Direction was co‑sponsored by the Department of Labor and the Ford Foundation, so one of the first that was government and private foundation funded. The focus again was on education and employment. They used a lot with peers, community support people, community group sessions, finding folks in the community to kind of work with young girls and to help them get a leg up. They followed girls to 12 and 24 months. At 12 months they saw a statistically significant difference in the teen pregnancy rates; at 24 months they did not.
Parents Too Soon is a program that was primarily funded by the Ounce of Prevention, in the Chicago area. This was a home visiting‑based program. And it included a lot of family support. Here they used a quasi‑experimental design comparing their population to the National Youth Survey. They saw a 1.4 times increased risk of a subsequent birth among the control group.
This second evaluation of this site showed marginal effect at 24 months. So again somewhat effective at 12 months. Marginally effective if at all at 24 months. The Teen Welfare Demonstration Project was funded by the Administration of Children and Family and the Department of Health and Human Services. This was a case management model that did use a randomized design. And they did show marginal significance at 24 months at one of the sites only.
New Chance was a program funded by the Department of Labor. They focused on life skills and employment. They used a case management model. They also focused a lot on child care and health education, and they didn't see any significant difference.
Early Headstart was funded by the Administration for Children Youth and Families. They used a randomized design. They did see a difference at 24 months.
So the conclusion is that mostly across these programs we saw marginal differences, if any, in the repeat pregnancy rates. The most successful programs were the ones that had more comprehensive emphasis on family planning and comprehensive sex ed.
The medical setting programs, of which there were four, these programs, as you can imagine, tended to have more of an emphasis on prenatal postpartum care but were more comprehensive and would involve things like child care, family planning, education, and perhaps other services, social worker services, that sort of thing, which you would all be familiar with. There were four of those. The Comprehensive Adolescent Program in Queens Hospital , the Teen Mother and Child Program, the Teen Baby Clinic and the West Dallas Youth Clinic.
Now, one caveat is that the evaluations of all of these programs were conducted in the 1980s. So these were a little dated and we needed to be aware of that in our thinking around this. One thing we need to think about that, for those of us in the field, is contraception has changed a lot from what we had available in the '80s, and I think that matters in some of our results.
The Queens program was both a prenatal and postpartum program with teens where they were assigned to a team that consisted of an obstetrician, a pediatrician, a social worker, and a health educator. They used a quasi‑experimental design again with this group comparing to teens who were not in this clinic. They did show a significant change during the adolescent period is how it's framed. I'm not sure exactly what that means. I guess they followed them until they aged out of adolescence. So that would be a different time period for each girl and they did show a difference.
The Teen Mother and Child Program was again a prenatal postnatal period. They followed these girls up to two years postpartum. It was a medical psychosocial and nutritionally based program. That's where the emphasis on their services. They used a quasi‑experimental design. They used a WIC group for their comparison group. They showed a marginal difference at 12 months and none beyond that.
The Teen Baby Clinic was enhanced postpartum care, as you can imagine. With a group of pediatricians, social workers, nurse practitioners, family planning counselors and regular counselors. They used a randomized design and they did show a significant difference at 18 months.
Then the West Dallas Youth Group was pre and postnatal clinic, school‑based. Prenatal care, nutrition, parenting classes, family planning referrals and some primary care. They used a quasi‑experimental design and they did not see a difference.
So some of the conclusions here: Two of these were marginally successful. One was clearly statistically significantly better, and one didn't have a difference. One of the clear differences, the one that showed the best significance, did have an emphasis on family planning.
Findings for the school‑based, of which there were three programs. Two of these were alternative schools and one was a program within a school. These again emphasized education, plus offered some medical and support needs.
There was the Poly Team McCabe Center , Special School Program and Second Chance Club. The Poly McCabe Center is an alternative high school for students. The way they set up their design, girls could come and stay through like, I think it was a six or 12 week postpartum period. Some elected to stay longer. They did their comparison between the girls who did just what they had to and the girls who elected to stay longer. Among the girls who elected to stay longer, they did see a statistically significant difference in repeat pregnancies and repeat births at both 24 and 60 months.
For the Special School Program, this was, they offered prenatal classes, teaching about labor and delivery, pregnancy, child birth and child care. They did a quasi‑experimental design to look at their findings and they only evaluated at 60 months and they did not see a change.
In the Second Chance, this was a South Carolina urban high school. This was a group that met weekly. They talked about parenting, career planning, participating in school events. There was a case management model. There was some home visits. There was medical care. There was a quasi‑experimental design used to evaluate this, and they did see a statistically significant difference at three years. So two of these has significant differences in their repeat pregnancy rates.
Home visiting, there were three of these programs. These programs combined education and support and generally followed an articulated curricula. The nurse family partnership or the Olds Model, which most of us are familiar with; the nurse visiting program in Memphis , and a teenage parent home visitor demonstration project. The Olds program, as we know, uses nurses to follow the girls who are pregnant up to two years of postpartum, with home visits. And we know that they do a lot of community and family support kind of interventions. They did not show a statistically significant difference at 12 months but did show one later among their populations.
The Memphis program is essentially the same as Olds, with the same outcome. The Teen Parent Home Visitor Services Demonstration program was a multi‑site demonstration program funded by Kaiser and the Administration for Children and Family. And they recruited teens who were receiving AFDC money or who were in job training programs. This was a home visiting program, which was kind of interesting, because they talked about the things that they provided, but this is a program that also sanctioned the teams for noncompliance. I always find that a little weird, so I needed to mention that.
And they in fact found increased birth among their cases. So much for sanctioning for noncompliant behavior. I say you get what you put out there, right? That's how I feel about it, that's my biases right there. So the conclusions are that the nurse based program was successful at 24, 36 and 45 but not at 12 and the demonstration project was not successful.
The contraceptive‑based programs of which there were two, these were participants who self‑selected to receive Norplant. There were two programs in Colorado , a Medicaid program and then an adolescent maternity program. They evaluated these because it was the time when Norplant was first being available and some, it was around the time they looked at data in 1991 before Medicaid would pay for Norplant among teens and 1992 when it would. And they looked at those two groups to do their comparison. And so they called this a natural experiment based upon the eligibility of Norplant. And so what they found is that there were statistically significant differences between these two groups at 12, 18, and 24 months. And in the Colorado visit, again, they saw differences at 12 and 24 months, and here they were inserting the Norplant in girls who wanted it after the delivery of their first child.
So the conclusions were they saw effects, which those who are familiar with Norplant, would assume you would. If you didn't, something is not right, right? Of course, it could be they came and had the Norplant taken out. But there you have it. So then this last slide shows four programs that were included that don't fall into neat categories but were four additional programs, one is the dollar a day program, which combined a financial incentive of a dollar for each nonpregnant day to girls who were part of this program, along with education and support through weekly meetings, and this was not successful.
UNIDENTIFIED SPEAKER: They need more money
PATRICIA PALUZZI: Right. The $20 a day program. They evaluated it at six, 12, 18, 24 months and didn't see any change in those time intervals. This was a Denver‑based program. The LEPP program is Ohio 's Learning Earning and Parenting Program. The primary focus was on teen moms to get them to graduate high school and to help assess the impact on their earnings. They used a randominzed assignment. They did not see any changes at 36 months, which is the only time they evaluated.
The Cal learning program was much like the LEPP program, also randomized; also didn't see any changes at 24 months. The Second Chance Homes are four familiar, has been a model that's been developed for pregnant teens who don't have a safe place to live or a place to live and helps them to transition to independent living. They haven't really begun to evaluate, there hasn't been a formal evaluation that's been published yet, although there's one in the works. The early information shows there may be a trend in delaying repeat pregnancies among young women who are in Second Chance homes.
Now, I wanted to talk about a case that's not in Klearman, because I think it kind of helps us to transition to some of what I think are sort of the themes that we see in her work as well as what we see in the field. At least from my perspective what we see in the field. Before I worked at the Healthy Teen Network I worked with the Baltimore City Health Department, Bureau Chief for Adolescent Reproductive Health. I am familiar with what with you do on some level.
We had a case management model there where we ran two case management models. I want to speak briefly, because we had some very interesting experiences with them. The first case management model was focused on preventing first pregnancies among teens, and it was done because it was part of a doctoral student's dissertation. She had three or four different interventions across multiple sites and did a quantitative analysis as to whether or not any of them were effective in delaying or preventing first pregnancies. The site I was overseeing had this case management model, and she and her quantitative analysis, showed statistically significant differences at six months and stopped there because she wanted to finish her dissertation and graduate.
However, in going back and looking at her data, her results began to wane by 12 months. I know later, because after we decided we had this evaluation, we wanted to have a qualitative assessment of it because if in fact this really worked, we wanted to understand what about the case management model was most effective, so we could replicate it. Because if we found the magic bullet we wanted to use it over and over again.
So we brought in a group, a Baltimore‑based group, CARTA, to do a qualitative assessment to help answer the questions what worked about this case management model. And in fact when they came back and said it didn't really work, because if you went back and looked at the data after six months, we no longer had a significant impact on preventing the pregnancies that we thought we had. However, what we did learn is what they said were the key pieces that were effective about the case management model, and the number one was that who the case managers were.
And the case managers, we were really fortunate, Baltimore is a predominantly majority African American city. And this was public clinics where every girl I think that was participating in this case management model was African American, as were all of the case managers. They were this incredibly charming 20 something group of young women who just really connected with these girls. They were really that sort of mentor near peer, took them under their wings, did an amazing job with them. And in the end...
PATRICIA PALUZZI: .....and I'm here to tell you that I think it worked in terms of the educational attainment. It worked in terms of girls were able to go on and do more things with their lives in terms of employment stuff. But, again, we brought some of the same evaluators in, and we just weren't able to capture the same group of case managers, so we didn't have that, the connection that the first group was able to make. And this turned out to be a critical feature.
And also I say all of this because both the times we focused these programs on educational and employment attainment. You saw earlier when you focus on that and not on pregnancy prevention, that's what you get; you don't get pregnancy prevention. This definitely goes along with sort of what Kirby showed us in New Emerging Answers when he did the ten characteristics of a successful teen pregnancy program, clear and consistent messages, about delaying sex or using safer sex. And if you're not doing that, then the girls are doing better in their education but they're not necessarily doing better in preventing subsequent pregnancy.
So what is some of the bottom line here of everything that we've talked about? That we think that some close and sustained relationships seem to be significant and that home‑based programs certainly foster this, as well as case management models potentially; that effective personnel and staff really matter, and that an emphasis on family planning, education and access to service also seems to matter.
And we know this, that even if you tell girls they have to go across the street or, in my situation, we had an STD clinic on the second floor of one of our health department buildings, and if you told people they had to go from the second floor to the first floor to get their birth control or the first floor to the second floor to get treated for the STD, they never quite made it, did they? They both pieces had to integrate. We all know if it's right there in the moment, you can deliver. If they have to go through hoops, you lose a lot of folks.
We also know that ‑‑ we also have some issues to resolve. Some of the issues that we have to resolve is what are the essential components of a home visiting program? And what about this issue of staff that closely resembles the clients versus nurses? And I bring this up because David Olds in his program will say to you that it was nurses that had to be a part of this program, and he was at our conference in November as well, and I asked him if they looked at the demographics of the nurses and did they control for that and what kind of a difference did that make. And he said they did control for that and it didn't make the difference. That what was significant to his program was they were professionally trained nurses and that their clients saw them as such and listened to them in that way. So he feels that you have to have nurses to have a successful home visiting model.
Now, we all know that's very expensive and isn't going to happen in a lot of settings, and also it goes against the grain of what we've heard about: You want people from the community, your peers, look like the population, know where the population is coming from, et cetera, et cetera. So what about reconciling that? There's a dual program in Chicago that's starting to spread a little bit that uses community workers to work with pregnant girls through labor and delivery and follow them afterwards and they use community folk that want to go on and have this training and they're having success in their early results in preventing births. And it's one we're grappling with, one that's hot in the field that we need to continue to think about, and also the emphasis on education or employment versus pregnancy prevention, and I think I've already sort of talked about that enough, but, again, calling the program what it is, because when we went back and assessed particularly the second program at the health department, none of these girls, they all called it, we called it like an empowerment program or something like that. So that's what they said it was. This is an empowerment program to get us a better education. We didn't really know it had anything to do with birth control. I mean basically they didn't get that message at all, even though it was sitting in a family planning clinic, you know, because we didn't give them that message in a direct enough way.
Next steps: What do we need? We need more and better evaluations obviously. You can see this report is a great report because it gives us a lot to work with. It tells us a lot about what we should be thinking about doing, as well as what we shouldn't probably be thinking about doing. But there were a lot of caveats to this. We know we need better evaluations in order to understand what's going on. And I'm a strong believer in qualitative information. I like the idea of mixed methods designs, and I think we need to be talking to people and figuring out more about what it is that does and doesn't work, because as I demonstrated with our project, you get a lot of ahas out of that that you don't get out of crunching the numbers.
We also need to consider the cost benefits of the types of programs, because while Carrera model, Olds Model, some of the ones we know are effective are expensive when we struggle how to deal with those. We need to figure out the cost benefit of some of these other programs.
We need to also delve into what makes program staff work. That shouldn't have a question mark after it. But it's a question. What is it about program staff that's particularly relevant, where should we put our efforts in our recruitment and training?
We need to insure that access to contraceptive education services are maintained. And I'll get on my policy soapbox for one moment and say this is being threatened at a lot of levels, a lot right now. We all have to be really diligent. Title X. A lot of Title X stuff is being threatened. Parental consent. There's a lot of legislation both across a lot of state levels. It's being turned around, and I will just tell you one report that came out recently of a county in Illinois where one county refused their Title X money, put parental consent as a mandate for teens accessing contraceptive services. I think they did that in 1998. A researcher published in the American Journal of Public Health in November, compared that county to other demographic similar counties in Illinois that did not impose parental consent already showing a increase in teen births.
So we know if we continue down the road that we're going our teen birth rates we saw going down are going to start to go back up. It's just going to happen. We all have to be really diligent and we all have to make sure that teens have access to what they need to full and comprehensive education and services.
And we say thank you very much for your time and attention, and we'll entertain any questions that you might have.
UNIDENTIFIED SPEAKER: (Inaudible)
PATRICIA PALUZZI: Right.
UNIDENTIFIED SPEAKER: (Inaudible)
PATRICIA PALUZZI: I agree. Right. I would totally agree about the community service aspect, that I'm involved in something here in DC where they're looking at they can't do a lot so what are the important things to do and the community service is a piece they're going to put in with education because it does seem to be a fairly inexpensive and wonderful way to do that. I don't remember seeing that included in any of the programs here in my reading, do you remember?
CINDY COSTELLO: I don't think ‑‑ it's a real interesting proposal, really, because to our knowledge, and (inaudible) Tina (inaudible) has been implemented and evaluated with the population of teens who are already mothers to try to prevent a second birth. But teen outreach is certainly, and for those who may not be familiar with teen outreach program, it's largely a school‑based community service program. It's a very intensive community service where the students have an opportunity to really talk about, learn from their community service experience, and then there is a health education piece to it. But it varies tremendously from place to place. And in fact, Susan (inaudible) one of the evaluators for teen outreach thinks the real critical piece is the community service piece. And in a day and age where we're all dealing with such tremendous political controversy over sex education, community service really needs to be looked at really really seriously. I believe in comprehensive sex Ed, but we also really have to look at what's making a difference. And a lot of the communities (inaudible) in our school systems could be bolstered. In Montgomery County (inaudible) community service (inaudible) but it's a very weak program. But it's a starting block, and I don't think you (inaudible) that program of any idea about the number of risky behaviors that community service can discourage.