Teen pregnancy prevention focusing on evidence: Ineffective abstinence-only lessons being replaced with science
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* Kim Krisberg

December marked a new day for sex education in America, with the elimination of federal abstinence-only funds and renewed support for evidence-based health curricula. Recent months also marked a new challenge for such efforts: For the first time in more than a decade, the U.S. teen pregnancy rate rose.

Shortly before the new year, President Barack Obama signed an appropriations bill that ended federal funding for existing abstinence-only-until-marriage programs and put a new teenage pregnancy prevention initiative in the newly funded Office of Adolescent Health within the U.S. Department of Health and Human Services. Supported with more than $114 million in federal funds, the prevention initiative is being hailed by health advocates for its focus on the evidence. Of the $114 million, $75 million will go toward replicating pregnancy prevention programs that have been thoroughly evaluated and provide the strongest evidence of success, while $25 million will go to programs that show promise and innovation. There are roughly 400,000 teen births every year in the United States, with about $9 billion in associated public costs.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/40/3/1.1/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/40/3/1.1/F1)

June DeLaRosa, a school nurse with Washington State’s Highland School District, teaches a health class in 2008. A 2007 state law set standards for sex education in Washington schools.

Photo by Andy Sawyer, courtesy Yakima Herald-Republic/AP Images

“This administration and this Congress have made a historic investment in preventing teen pregnancy,” said Bill Albert, chief program officer at the National Campaign to Prevent Teen and Unplanned Pregnancy. “In our view, this investment could not be more timely given the fact that the teen pregnancy rate in the United States is on the rise. I think one might say, without hyperbole, that one of the nation’s great success stories of the past two decades may be in danger of unraveling. So, this investment is right on for content and right on for timeliness.”

While the nation’s teen pregnancy rate declined about 40 percent between 1990 and 2005, data released by the Guttmacher Institute in late January showed that the rate rose 3 percent in 2006. According to the institute, the new data is “especially noteworthy because they provide the first documentation of what experts have suspected for several years, based on trends in teens’ contraceptive use — that the overall teen pregnancy rate would increase in the mid-2000s following steep declines in the 1990s and a subsequent plateau in the early 2000s.” And like many other health issues, the U.S. teen pregnancy rate is checkered with disparities. In 2006, among black and Hispanic teens ages 15 to 19, there were about 126 pregnancies per 1,000 women, while among white teens, it was 44 per 1,000. Such statistics mean the United States has the unfortunate honor of having the highest teen birth rate among Western, industrialized nations.

“As a society, we have to continually redouble our efforts to sustain these kinds of (downward) trends over time,” said Heather Boonstra, MA, senior public policy associate at the Guttmacher Institute, which conducts research on a range of sexual and reproductive health issues. “We can’t just sit back because new teens are constantly coming into the field and we have to remain vigilant.”

Factors shaping the recent rise in teen pregnancy are varied and complex, prevention advocates say, ranging from years of federal support for rigid abstinence-only programs to tempered fears of contracting HIV to less teen contraceptive use. According to the 2007 National Youth Risk Behavior Survey, conducted by the Centers for Disease Control and Prevention, rates of teens who were sexually active and those who used a condom during their last sexual encounter remained statistically stalled from 2005 to 2007, following years of positive behavior change. Of teens who were sexually active, only about 61 percent used a condom the last time they had sex, CDC reported. According to Lorrie Gavin, PhD, MPH, a health scientist within CDC’s Division of Reproductive Health, current trends point to more than just a teen pregnancy problem — “there’s something else going on…improvements in sexual risk behavior have leveled off in recent years and rates of some sexually transmitted diseases have increased.”

“We have the tools we need (to prevent teen pregnancy and disease) — and we can always improve on them — but we need to better apply them,” Gavin told *The Nation’s Health*. “In addition to disseminating evidence-based sexuality education and youth development programs, it is critically important that we make sure that sexually active youth have access to contraceptive services and that there is a supportive social and policy environment.”

With a focus on the evidence, the new federal teen pregnancy initiative could go far in creating such an environment, say prevention advocates, many of whom criticized previous federal support of often ineffective abstinence-only programs. Federal funding of abstinence-only programs increased significantly beginning in the mid-1990s and since 1998, $50 million per year was going toward programs that teach abstinence from sex outside of marriage. To qualify for the federal funds, states had to stick to strict curricula guidelines. For example, programs had to teach that marriage is the only appropriate context for sexual activity — an often disparaging point for gay, lesbian, bisexual and transgender youth — and could not advocate contraceptive use or discuss condoms outside of their failure rates.

Follow-up studies on youth taking part in such abstinence-only programs found that, for the most part, the programs were no more effective at encouraging kids to delay sex than other programs and, in fact, participants in abstinence-only programs were more likely to have erroneous views of condoms and their effectiveness. The debate over such effectiveness recently made headlines again after a study published in the February issue of *Archives of Pediatrics and Adolescent Medicine* found that one specific abstinence-based intervention was successful at delaying sexual initiation. However, the study authors noted that the intervention studied “would not meet federal criteria for abstinence programs… (and) was not moralistic and did not criticize the use of condoms.”

Albert at the National Campaign to Prevent Teen and Unplanned Pregnancy said that most Americans do not necessarily view the sex education debate as one of “competing strategies, but of complementary strategies,” adding that the “American public wants their money spent on things that have an evidence of success.” For the Obama administration, the sticking point will be evidence, not content, Albert said.

“It used to be, to get this federal pot of money, you had to stick to a certain curriculum — the variable was content, not evidence,” Albert told *The Nation’s Health*. “Now, our ‘sort variable’ is going to be evidence, and for geeks like us, that’s music to our ears.”

It is welcome news to many state-based groups as well, such as the 25-year-old Adolescent Pregnancy Prevention Campaign of North Carolina, which partially credits the state’s 30-year low in teen pregnancy rates to the implementation of evidence-based community approaches. According to Sally Swanson, the campaign’s director of prevention programs, the campaign mostly collaborates with workers in community settings, as strict state and federal rules dictated school-based education. But with the change at the federal level and a new 2009 state law that removed rigid restrictions on sex education curricula, Swanson said she no longer feels like a proverbial salmon always moving against the current.

“This is a social justice issue,” Swanson told *The Nation’s Health*. “It’s a delicate issue because it’s not a horrible thing to have a baby, but the opportunities available for that young mother and child are diminished and the impacts for society are significant.”

While garnering praise, advocates warn that the new federal teen pregnancy prevention effort is not necessarily permanent, and that abstinence-only-until-marriage proponents are not giving up. In the health reform bill passed by the U.S. Senate in December, Sen. Orrin Hatch, R-Utah, successfully included an amendment to restore $50 million a year in abstinence-only state funds — a move that if signed into law would extend abstinence-only funds by another five years. In addition, funds for Obama’s new teen pregnancy prevention effort must be reappropriated by Congress every year, which means its future is far from secure.

“We all need to take a moment and breathe and celebrate how far we’ve come, but we can’t sit back and rest on our laurels,” said Jen Heitel Yakush, director of public policy at the Sexuality Information and Education Council of the United States. “We need to remain vigilant. We have such an opportunity to get information to young people while they are still thinking about what it means to be sexually healthy.”

For more information on teen pregnancy prevention and sexuality education, visit [www.thenationalcampaign.org](http://www.thenationalcampaign.org) or [www.siecus.org](http://www.siecus.org).

*   Copyright The Nation’s Health, American Public Health Association