Teenage Pregnancy Prevention: Statistics and Programs

. Teenage Pregnancy Prevention: Statistics and Programs Carmen Solomon-Fears Specialist in Social Policy February 3, 201126, 2015 Congressional Research Service 7-5700 www.crs.gov RS20301 CRS Report for Congress Prepared for Members and Committees of Congress c11173008 . Teenage Pregnancy Prevention: Statistics and Programs Summary In 20092013, U.S. teen births accounted for 10.17.0% of all births and 2115.4% of all nonmarital births. The birth rate for U.S. teenagers (ages 15 through 19) increased in 2006 and 2007 after a steady decline since 1991. However, in 2008 and 2009each of 2008 through 2013, the teen birth rate dropped below the 2007 2006 teen birth rate, reversing the two-year upward trend. Although the birth rate for U.S. teens has dropped in 16 in 21 of the last 18past 23 years, it remains higher than the teenage birth rate of most industrialized nations. In recognition of the negative, long-term consequences associated with teenage pregnancy and births, the prevention of teenage and out-of-wedlock childbearing is a major goal of this nationteen birth rate of most industrialized nations. Preventing teen pregnancy is generally considered a priority among policymakers and the public because of its high economic, social, and health costs for teen parents and their families. The Adolescent Family Life (AFL) program, created in 1981 (Title XX of the Public Health ServicesService Act), was the first federal program to focus on pregnancy among adolescents. It was created to support demonstration projects that provide comprehensive and innovative health, education, and social services to pregnant and parenting adolescents, their infants, male partners, and their families. From 1998 to 2009, federal teen pregnancy prevention efforts in the AFL program and in general relied heavily on using abstinence-only education as their primary tool. It appears that a consensus is now growing around the viewpoint that success in the teen pregnancy prevention arena does not necessarily have to be an “either-or” proposition in which abstinence-only education programs are pitted against comprehensive sex education programs. P.L. 111-117 (the Consolidated Appropriations for FY2010The appropriation for the AFL program was $16.7 million in FY2010 and $12.4 million for FY2011. The AFL program has not received any funding since FY2011. P.L. 111-117 (Consolidated Appropriations Act, 2010) included a new discretionary Teen Pregnancy Prevention (TPP) program, funded at $110 million for FY2010, which provides grants and contracts, on a competitive basis, to public and private entities to fund “medically accurate and age appropriate” programs that reduce teen pregnancy. P.L. 111-148 (the health care reform law) established a new state formula grant program and appropriated $375 million at $75 million per year for five years (FY2010-FY2014) to enable states to operate a new Personal Responsibility Education Program (PREP), which is a comprehensive approach to teen pregnancy prevention that educates adolescents on both abstinence and contraception to prevent pregnancy and sexually transmitted diseases. PREP also Since FY2010, funding for the TPP program has fluctuated from a high of $109 million in FY2011 to a low of $98.4 million in FY2013 (post-sequester). P.L. 113-76 (the Consolidated Appropriations Act, 2014) provided $101 million for the TPP program (and $8.5 million for program evaluation) for FY2014. Pursuant to P.L. 113-235 (the Consolidated and Further Continuing Appropriations Act, 2015), the TPP program is funded at $101 million for FY2015 (plus $6.8 million for program evaluation). P.L. 111-148 (the Patient Protection and Affordable Care Act-ACA) established a new state formula grant program and appropriated $375 million, at $75 million per year for five years (FY2010-FY2014), to enable states to operate a new Personal Responsibility Education Program (PREP), which is a broad approach to teen pregnancy prevention that educates adolescents on both abstinence and contraception to prevent pregnancy and sexually transmitted diseases. PREP also provides youth with information on several adulthood preparation subjects (e.g., healthy relationships, adolescent development, financial literacy, parent-child communication, educational and career success, and healthy life skills). P.L. 113-93 (the Protecting Access to Medicare Act of 2014), which was enacted on April 1, 2014, extended PREP ($75 million per year) through FY2015 (i.e., September 30, 2015). The Title V Abstinence Education Block Grant to states was authorized under P.L. 104-193 (the 1996 welfare reform law). The Title V Personal Responsibility and Work Opportunity Reconciliation Act of 1996). The Title V Abstinence Education program is a formula grant program, specifically for abstinence-only education, funded by mandatory spending. The program’s funding expired on June 30, 2009, but P.L. 111-148 reauthorized the program and restored funding to it funding at the previous annual level of $50 million for each of FY2010-FY2014. There are many other federal programs that can provide pregnancy prevention information and/or services to teens. They include Title X Family Planning, Medicaid family planning, the Maternal and Child Health block grant, the Title XX Social Services block grant, the TANF block grant, and several other Department of Health and Human Services (HHS) programs. This report briefly million for each of FY2010-FY2014. P.L. 113-93 extended the Title V Abstinence Education block grant ($50 million per year) through FY2015. Congressional Research Service Teenage Pregnancy Prevention: Statistics and Programs Several appropriation laws included an additional $5 million for competitive grants for abstinence-only education for each of FY2012, FY2013, FY2014, and FY2015 (P.L. 112-74, P.L. 113-6, P.L. 113-76, and P.L. 113-164/P.L. 113-235). This report briefly examines some of the data collected by the National Center for Health Statistics on teenage childbearing, offers potential reasons for high teen pregnancy and birth rates, and provides basic information on federal programs whose purpose, in whole or part, is to prevent teen pregnancy and reduce teen births is primarily to delay sexual activity among teenagers and to reduce teen pregnancy. The Appendix provides a funding history of the teen pregnancy prevention programs discussed in this report. Congressional Research Service . Teenage Pregnancy Prevention: Statistics and Programs Contents Introduction ...................................................................................................................................... 1 Teenage Births in the United States ................................................................................................. 21 National Trends .......................................................................................................................1.. 2 State Data/Trends .....................................................................................................................2.. 3 Some Demographic Features and Trends ...............................................................................2 Age of Fathers ......................................................................................................................................... 3 Financial and Social Costs of Teen Births ................................................................................3. 4 Reasons for High Pregnancy and Birth Rates Among Teens ...........................................................4 5 Decline in Pregnancy/Birth Rates ..........................................................................................4.... 6 Federal Strategies to Reduce Teen Pregnancy ..............................................................................5 Comprehensive Sex Education ..............................................................................................5 Teen Pregnancy Prevention Program ...............................................................................6 Personal Responsibility Education Program ....... 7 1981-1996: Reducing Pregnancies and Helping Adolescent Mothers....................................... 9 1996-2009: Abstinence Only ................................................................6 Evaluation of Comprehensive Sex Education Programs...................................................7 Abstinence Education 10 2009-Present: Evidence-Based ............................................................................................................8 Title V Abstinence Education ..... 10 Federal Teen Pregnancy Prevention Programs .....................................................................................8 Community-Based Abstinence Education 12 Teen Pregnancy Prevention (TPP) Program .............................................................................9 Adolescent Family Life Program—“Prevention” Component ..........................................9 Evaluation of Abstinence Education Programs 12 Personal Responsibility Education Program ............................................................................ 10 Youth Programs .... 14 Title V Abstinence Education .............................................................................................................. 11 Evaluation of Youth Programs 16 Adolescent Family Life Program .......................................................................................... 12 Other Federal Programs to Reduce Teen Pregnancy............ 17 Community-Based Abstinence Education (CBAE) Program ......................................................... 13 The Adolescent Family Life (AFL) Program: Title XX of the Public Health Services Act. 18 Competitive Abstinence-Only Grants .................................................................................................................................. 13 Reproductive Health and Family Planning Services: Title X of the Public Health Services Act .......... 19 Other Federal Programs ........................................................................................................... 14 Maternal and Child Health (MCH) Block Grant: Title V of the Social Security Act.............. 14 Medicaid: Title XIX of the Social Security Act.................................................................... 14 Social Services Block Grant: Title XX of the Social Security Act ........................................ 14 Temporary Assistance for Needy Families (TANF): Title IV-A of the Social Security Act................................................................................................................................... 14 The National Strategy to Prevent Out-of-Wedlock Teen Pregnancies ................................... 15 Figures Figure 1. Teen Birth Rates (Ages 15-19), 1950-2009 ...................................................................2 Contacts Author Contact Information 19 Evaluation of Teen Pregnancy Prevention Programs ..................................................................... 20 Figures Figure 1. Teen Birth Rates (Ages 15-19), 1950-2013 ...................................................................... 3 Tables Table A-1. Federal Teen Pregnancy Prevention Program Funding, FY1998-FY2015 .................. 24 Appendixes Appendix. Federal Teen Pregnancy Prevention Program Funding: FY1998-FY2015 ................. 24 Contacts Author Contact Information....................................................................................................... 15.... 26 Congressional Research Service . Teenage Pregnancy Prevention: Statistics and Programs Introduction In 20062010, an estimated 743,000614,400 U.S. teenagers (ages 15-19) became pregnant, approximately 107,000 had 89,300 had miscarriages, and 200,000157,500 had legal abortions (latest available data).1 The result was that there were 435,000nearly 367,700 births to teenagers in 2006. In 2009, 10.1that year. In 2013, 7.0% of all U.S. births were to teens, and 21 15.4% of all nonmarital births were to teens. In recognition of the negative, long-term consequences associated with teenage pregnancy and births, the prevention of teenage and out-ofwedlock childbearing is a major goal of this nation. Although the birth rate for U.S. teens has dropped in 16 of the last 18 years, it remains higher than the teenage birth rate of most industrialized nations. According to a 2010 report: Teen childbearing is associated with adverse health and social outcomes for teen mothers and their children, although these outcomes often reflect preexisting social deficits. Compared with women who delay childbearing until their 20s, teen mothers are more likely to drop out of school and have low educational attainment; to face unemployment, poverty, and welfare dependency; to experience more rapid repeat pregnancy; to become single mothers; and to experience divorce, if they marry. Infants of teen mothers are more likely to be premature and experience infant mortality. The children of teenage mothers do less well on indicators of health and social wellbeing than do children of older mothers.2 In recognition of the negative, long-term consequences associated with teenage pregnancy and births, the prevention of out-of-wedlock pregnancies3 is a major goal of this nation. Reducing nonmarital childbearing is one of the explicit goals that were stipulated in the 1996 welfare reform law.4 Although the birth rate for U.S. teens has dropped in 21 of the last 23 years, it remains higher than the teenage birth rate of most industrialized nations.5 1 Kathryn Kost and Stanley Henshaw, U.S. Teenage Pregnancies, Births and Abortions, 2010: National and State Trends by Age, Race and Ethnicity, Guttmacher Institute, May 2014, p. 10. 2 John S. Santelli and Andrea J. Melnikas, “Teen Fertility in Transition: Recent and Historic Trends in the United States,” Annual Review of Public Health 2010, vol. 31, pp. 371-383. 3 As noted later, 89% of births to females under age 20 were nonmarital births (i.e., births to unmarried women) in 2013. Note that although P.L. 104-193 uses pregnancies as the policy variable, in practice births have become the indicator because birth data are more current and reliable than pregnancy data. 4 Pursuant to P.L. 104-193 (the 1996 welfare reform law), states may use Temporary Assistance for Needy Families (TANF) funds in any manner “reasonably calculated” to achieve the four goals set forth in TANF statute. These four goals are (1) provide assistance to needy families so that children may be cared for in their own homes or in the homes of relatives; (2) end the dependence of needy parents on government benefits by promoting job preparation, work, and marriage; (3) prevent and reduce the incidence of out-of-wedlock pregnancies and establish annual numerical goals for preventing and reducing the incidence of these pregnancies; and (4) encourage the formation and maintenance of twoparent families. The bulk of federal TANF funding is in a basic block grant totaling $16.5 billion for the 50 states and the District of Columbia. 5 For further information on a comparison of U.S. teen birth rates with those of other countries, see “Fast Facts: How Does the United States Compare?” at http://www.thenationalcampaign.org/national-data/teen-pregnancy-birthrates.aspx. Also see Gilda Sedgh, Lawrence B. Finer, Akinrinola Bankole, Michelle A. Eilers, and Susheela Singh, “Adolescent Pregnancy, Birth, and Abortion Rates Across Countries: Levels and Recent Trends,” Journal of Adolescent Health, vol. 56, issue 2, February 2015, pp. 223-230. Congressional Research Service 1 Teenage Pregnancy Prevention: Statistics and Programs Teenage Births in the United States National Trends In 1950, the number of births to U.S. females under age 20 was 438,000; by 1960, births to teens had increased nearly 36% to 593,746; and by 1970 they had increased another 11% to 656,460. Since then, the number of births to teens has generally declined, with some upward fluctuations. Births to teenagers declined 3758% from 1970 to 2009; 262013; 51% from 1980 to 2009; 222013; 48% from 1990 to 2009, and 13% from 2000 to 2009. In 20092013; 42% from 2000 to 2013; and 26% from 2010 to 2013. In 2013, the number of births to teens was 414,870276,203 (of which 5,030 3,098 births were to girls under age 15).26 As shown in Figure 1, the peak birth rate for U.S. teenagers occurred in 1957, with 96.3 births per 1,000 women ages 15-19. The 20092013 teenage birth rate of 39.126.5 per 1,000 women ages 15-19 is 6about 10% lower than the 20082012 teenage birth rate (22% below the 1986 low of 50.2 births per 1,000 female teens). Teenage birth rates increased during the late 1940s (i.e., the “baby boom” years after World War II) and 1950s, decreased during the 1960s and early 1970s, remained relatively stable between 1975 and 1988, increased sharply during the late 1980s, declined every year from 1991 through 2005, and then increased in 2006 and 2007. The 2009 teen birth rate (39.1 births per 1,000 teens ages 15-19) was below the previous all-time low 2013 teen birth rate (4026.5 births per 1,000 teens in 2005). In 1950, teens (ages 15-19) gave birth at the rate of 81.6 per 1,000 teens, compared to 61.8 per 1,000 teens in 1991, 40.5 per 1,000 teens in 2005, 41.9 per 1,000 teens in 2006, 42.5 per 1,000 teens in 2007, 41.5 per 1,000 teens in 2008, and 39.1 per 1,000 teens in 2009. teens ages 15-19) is currently the lowest teen birth rate recorded.7 Although the number of births to females under age 20 decreased 2248% from 1991 to 2009, 2013, the birth rate of teens ages 15 through 19 declined by 3757% in the same period.8 The smaller decline in the number of births to teens compared with the teen birth rate is due to an increase in the number of teenage females in the 1990s. In 20092013, the birth rate for teenagers ages 15-17 was down 48% 12.3 per 1,000 teens ages 15-17, down 68% from 1991. For teens ages 18 and -19, the birth rate dropped by 30% from 1991 to 2009. In 2009, of the 414,870 births to females under age 20, 87% (362,490 births) were to unmarried teenagers. With fewer teens entering into 1 Guttmacher Institute, “U.S. Teenage Pregnancies, Births and Abortions: National and State Trends and Trends by Race and Ethnicity,” updated January 2010, p. 7. 2 Brady E. Hamilton, Joyce A. Martin, and Stephanie J. Ventura, “Births: Preliminary Data for 2009,” National Vital Statistics Reports, vol. 59, no. 3, December 21, 2010. Hereafter referred to as “Births: Preliminary 2009 Data.” Congressional Research Service 1 . Teenage Pregnancy Prevention: Statistics and Programs marriage, the proportion of births to unmarried teens has increased dramatically (87% in 2009 versus 29% in 1970). Figure 1.Teen Birth Rates (Ages 15-19), 1950-2009 120 Rate Peaked in 1957 at 96.3 Birth Rate per 1,000 Females Ages 15-19 100 80 60 40 20 Rate in 2009: 39.1 0 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 was 47.1 per 1,000 teens ages 18-19, down 50% from 1991.9 In 2013, of the 276,303 births to females under age 20, 89% (245,239 births) were to unmarried teenagers.10 With fewer teens entering into marriage, the proportion of births to unmarried teens has increased dramatically (89% in 2013 versus 29% in 1970). 6 Joyce A. Martin, Brady E. Hamilton, Michelle J.K. Osterman, Sally C. Curtin, and T.J. Mathews “Births: Final Data for 2013,” National Vital Statistics Reports, vol. 64, no. 1, January 15, 2015, Table 2. 7 For additional information, see Brady E. Hamilton and Stephanie J. Ventura, “Birth Rates for U.S. Teenagers Reach Historic Lows for All Age and Ethnic Groups,” NCHS Data Brief, no. 89, April 2012, Table for Figure 6. 8 According to the Center for Disease Control and Prevention (CDC), if the 1991 birth rates had prevailed, there would have been an estimated 3.4 million additional births to teenagers from 1992 through 2010. (Source: Brady E. Hamilton and Stephanie J. Ventura, “Birth Rates for U.S. Teenagers Reach Historic Lows for All Age and Ethnic Groups,” NCHS Data Brief, no. 89, April 2012, p. 3.) 9 Although this report focuses on teenagers, young adults ages 20-24 also have high birth rates. In 2013, for young adults ages 20-24, the birth rate was 80.7 per 1,000 young adults ages 20-24; down 30% from 1991. 10 Joyce A. Martin, Brady E. Hamilton, Michelle J.K. Osterman, Sally C. Curtin, and T.J. Mathews “Births: Final Data for 2013,” National Vital Statistics Reports, vol. 64, no. 1, January 15, 2015, Table 2 and Table 15. Congressional Research Service 2 Teenage Pregnancy Prevention: Statistics and Programs Figure 1.Teen Birth Rates (Ages 15-19), 1950-2013 120 Rate Peaked in 1957 at 96.3 Birth Rate per 1,000 Females Ages 15-19 100 80 60 40 20 Rate in 2013: 26.5 0 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 Year Source: Chart prepared by the Congressional Research Service (CRS), based on data from the National Center for Health Statistics, Department of Health and Human Services (HHS). State Data/Trends Teen birth rates vary considerably from state to state. The birth rate of teens (ages 15-19) decreased in 14 states (and 1 jurisdiction) from 2007 to 2008; increased in 1 state (Montana); and remained virtually unchanged in 35 states (and 5 jurisdictions). Nonetheless, during the period 1991-2005, a reduction in the rate of births among teens ages 15-19 was observed in all 50 states, the In 2013, the state with the lowest reported rate was Massachusetts, at 12.1 births per 1,000 women (ages 15-19); the state with the highest reported rate was Arkansas, at 43.5 births per 1,000 women (ages 15-19).11 From 2012 to 2013, the birth rate of teens (ages 15-19) decreased or did not change significantly in all 50 states, the District of Columbia, Guam, Puerto Rico, the Virgin Islands, American Samoa, and the Northern Mariana Islands. In 2008, the lowest reported rate was in New Hampshire, at 19.8 births per 1,000 women (ages 15-19), and the highest reported rate was in Mississippi, at 65.7 births per 1,000 women (ages 15-19).3 Northern Mariana Islands.12 Some Demographic Features and Trends After having declined for all racial and ethnic groups during the period from 1991 to 2005, the teen birth rate increased for white, black, and American Indian/Alaska Native women ages 15 through 19 from 2005 to 2007.4 In 2008, the13 The teen birth rates for women ages 15 through 19 3 decreased for 11 Joyce A. Martin, Brady E. Hamilton, Paul D. Sutton , Stephanie J. Ventura, T.J. Mathews, and Michelle J. K. Osterman,Michelle J.K. Osterman, Sally C. Curtin, and T.J. Mathews “Births: Final Data for 20082013,” National Vital Statistics Reports, vol. 59, no. 1, December 2010, Table B. (Hereafter referred to as “Births: Final 2008 Data.”) 4 “Births: Preliminary 2009 Data,” Table 5. Congressional Research Service 2 . 64, no. 1, January 15, 2015, Table 12. 12 Ibid. 13 Joyce A. Martin, Brady E. Hamilton, Stephanie J. Ventura, Michelle J.K. Osterman, and T.J. Mathews, “Births: Final Data for 2011,” National Vital Statistics Reports, vol. 62, no. 1, June 28, 2013, Table A. Congressional Research Service 3 Teenage Pregnancy Prevention: Statistics and Programs dropped below their respective 2007 levels for all racial and ethnic groups. Similarly, in 2009 the teen birth rates for women ages 15 through 19 dropped below their respective 2008 levels for all racial and ethnic groups. Between 2007 and 2009, teen birth rates fell 14.3% for Hispanic teens, 13.6% for Asian/Pacific Islander teens, 8.1% for black teens, 6.4% for American Indian/Alaska Native teens, and 5.9% for white teens. However, birth rates for Hispanic and blackall racial and ethnic groups during the period 2007 to 2013.14 From 2007 to 2013, teen birth rates (for women ages 15 through 19) fell 45% for Hispanic teens, 41% for Asian/Pacific Islander teens, 37% for American Indian/Alaska Native teens, 37% for black teens, and 32% for white teens. However, birth rates for Hispanic, black, and American Indian/Alaska Native teenagers continue to be much higher than that of other racial/ethnic groups. In 20092013, Hispanic teens (ages 15-19) gave birth at a rate of 70.141.7 per 1,000 Hispanic teens. Non-Hispanic blackBlack teens gave birth at a rate of 59 39.0 per 1,000 non-Hispanic black teens. In contrast, American Indian/Alaska Native teenagers teens gave birth at a rate of 55.531.1 per 1,000 American Indian/Alaska Native teens, nonHispanic. In contrast, white teens gave birth at a rate of 25.6 18.6 per 1,000 non-Hispanic white teens, and Asian/Pacific Islander teens gave birth at the lowest rate, 14.68.7 per 1,000 Asian/Pacific Islanders teens. 515 Also noteworthy is the decline in subsequent births among teens. In 1951, 28% of all teen births were second or higher-order births, compared to 19% in 2009.6 Age of Fathers According to one study, about one in five births to unmarried, teenage girls is attributed to men at least five years older than the mother.7 The information on fathers’ age has fueled legislative action at the state and local level. Statutory rape laws are viewed by several states as a deterrent to teen pregnancy and birth—the premise being that older men will avoid sexual relations with an adolescent if criminal charges are likely to be brought. According to the 2002 National Survey of Family Growth, among unmarried men ages 25-29, 8% had a female partner in the past 12 months who was 7 or more years younger than himself.8 Financial and Social Costs of Teen Births An October 2006 study by the National Campaign to Prevent Teen Pregnancy estimated that, in 2004, adolescent childbearing cost U.S. taxpayers about $9 billion per year: in child welfare benefits, $2.3 billion; in health care expenses, $1.9 billion; in spending on incarceration (for the sons of women who had children as adolescents), $2.1 billion; in lost tax revenue because of lower earnings of the mothers, fathers, and children (when they were adults), $6.3 billion; and in offsetting public assistance savings (younger teens receive less annually over a 15-year period than those who give birth at age 20-21), $3.6 billion. Research indicates that teens who give birth are less likely to complete high school and go on to college, thereby reducing their potential for economic self-sufficiency. The research also indicates that the children of teens are more likely than children of older parents to experience problems in school and drop out of high school, and as adults are more likely to repeat the cycle of teenage pregnancy and poverty. The 2006 report 5 “Births: Preliminary 2009 Data,” Table 5. “Births: Preliminary 2009 Data,” Table 3. 7 “How Old Are U.S. Fathers?” by David J. Landry and Jacqueline D. Forrest, Family Planning Perspectives, vol. 27, no. 4, 1995. 6 8 Centers for Disease Control and Prevention. Fertility, Contraception, and Fatherhood: Data on Men and Women from Cycle 6 (2002) of the National Survey of Family Growth, by Gladys M. Martinez, Anjani Chandra, Joyce C. Abma, Jo Jones, and William D. Mosher. National Center for Health Statistics, Series 23, No. 26. 2006. Congressional Research Service 3 . Teenage Pregnancy Prevention: Statistics and Programs contends that if the teen birth rate had not declined between 1991 and 2004, the annual costs associated with teen childbearing would have been almost $16 billion (instead of $9 billion).9 Reasons for High Pregnancy and Birth Rates Among Teens The high volume of pregnancies and birth rates among teenage and never-married women is often attributed to a liberal view of sexual activity.10 Some analysts also contend that contraceptive advancements have afforded women a false sense of security, thereby contributing to increased sexual activity and more pregnancies. The academic and professional communities also maintain that teen parenthood is one of the negative consequences of growing up without a father.11 Moreover, policymakers suggest that, prior to reform, “welfare” was seen as a guaranteed source of income for unmarried teenage mothers with grim marriage and job prospects. The president of the Alan Guttmacher Institute, commenting on a study about adolescent pregnancy and childbearing in “developed” countries, stated: “In the United States, poverty and inequity clearly are behind much of our high rates of pregnancy, birth and abortion. But lack of sensitive, confidential, low-cost contraceptive services and the denial of accurate and frank information about sex, are equally to blame.”12 Decline in Pregnancy/Birth Rates One reason given for the historical decline (1991-2005) in teen pregnancies and births is that sexually active female teenagers have significantly increased their use of contraceptives, particularly condoms. The more effective and consistent use of contraception has been facilitated by long-lasting injectable (Depo Provera) and implanted (Norplant) devices that are readily available to female teens. Abstinence campaigns, aimed at younger teens, are also seen as having a positive effect on pregnancy prevention. Moreover, casual sex, which may increase the risk of sexually transmitted diseases (STDs) and may prove to be fatal given the presence of HIV/AIDS, is viewed in an increasingly negative light by many teenagers. Some observers attribute the return to the long-term downward trend in teen birth rates (after the two year increase in 2006 and 2007) to the severe recession that began in 2008. They contend that the decrease in teen births—like the decrease in overall births—is, in part, because teenagers are being more careful as they witness the economic difficulties faced by their families.13 9 The National Campaign to Prevent Teen Pregnancy, By the Numbers: The Public Cost of Teen Childbearing, by Saul D. Hoffman. October 2006. 10 U.S. Congress, House Ways and Means, Subcommittee on Human Resources, Testimony of Dr. Isabel V. Sawhill on Nonmarital Births and Child Poverty in the United States, June 29, 1999. 11 General Accounting Office, Teen Pregnancy: State and Federal Efforts to Implement Prevention Programs and Measure Their Effectiveness, GAO/HEHS-99-4, November 1998. 12 Alan Guttmacher Institute, United States and the Russian Federation Lead the Developed World in Teenage Pregnancy Rates, News Release, February 24, 2000, p. 2. 13 Rob Stein, “Birthrate Among Teens Hits Record Low,” Washington Post, December 22, 2010, A02. Congressional Research Service 4 . Teenage Pregnancy Prevention: Statistics and Programs Federal Strategies to Reduce Teen Pregnancy In recognition of the negative, long-term consequences of teen pregnancy and births, the prevention of teenage and nonmarital childbearing is a major goal of this nation. Although the pregnancy rate, birth rate, and abortion rate for teens have all dropped in recent years, the teen birth rate in the United States is still far above that of most industrialized countries. The U.S. teen birth rate was one and one-half times that of the United Kingdom and 11 times that of the Netherlands. In 2006, teen birth rates were 4 births per 1,000 teens ages 15-19 in the Netherlands; 5 per 1,000 in Japan; 10 per 1,000 in Germany; 13 per 1,000 in Canada; 27 per 1,000 in the United Kingdom; and 42 per 1,000 in the United States.14 When the idea of abstinence-only education was being discussed during the 1994-1996 welfare reform debate it was in the context of providing equal funding for abstinence education as was then provided for teen sexual education programs that included information about contraception and sexually transmitted diseases. It appears that a consensus is now growing around the viewpoint that success in the teen pregnancy prevention arena does not necessarily have to be an “either or” proposition in which abstinence-only education programs are pitted against comprehensive sex education programs. This section discusses three approaches to reducing teen pregnancy: comprehensive sex education, abstinence-only education, and youth programs that address teen pregnancy. Comprehensive Sex Education Advocates of a comprehensive approach to sex education argue that today’s youth need information and decision-making skills to make realistic, practical decisions about whether to engage in sexual activities. They contend that such an approach allows young people to make informed decisions regarding abstinence, gives them the information they need to set relationship limits and to resist peer pressure, and also provides them with information on the use of contraceptives and the prevention of sexually transmitted diseases.15 Given that about 50% of high school students have experienced sexual intercourse, 16 advocates argue that abstinence-only messages provide no protection against the risks of pregnancy and disease for these youth. They further point out that according to one study, teens who break their virginity pledges were less likely to use contraception the first time than teens who had never made such a promise.17 In addition, the high number of females under age 25 with sexually transmitted diseases (STDs)18 14 United Nations Statistics Division, “Demographic Yearbook 2006,” http://www.thenationalcampaign.org/resources/ pdf/TBR_InternationalComparison2006.pdf. See also “Adolescent Pregnancy and Childbearing: Levels and Trends in Developed Countries,” by Susheela Singh and Jacqueline E. Darroch, Family Planning Perspectives, Alan Guttmacher Institute, vol. 3, no. 1, January/February 2000, pp. 14-23. 15 Some contend that the abstinence-only approach leads to a substitution of other risky behaviors such as oral sex. They cite data that indicate that about 25% of virgin teens ages 15 through 19 have engaged in oral sex. Source: Child Trends Data Bank, “New Indicator on Oral Sex,” September 15, 2005, at http://www.childtrendsdatabank.org/ whatsNew.cfm. 16 For more information on sexual activity of high school students, see Congressional Research Service, CRS Report RS20873, Reducing Teen Pregnancy: Adolescent Family Life and Abstinence Education Programs, by Carmen Solomon-Fears. 17 Peter S. Bearman and Hannah Bruckner, “Promising the Future: Virginity Pledges as They Affect the Transition to First Intercourse,” American Journal of Sociology, January 2001. Congressional Research Service 5 . Teenage Pregnancy Prevention: Statistics and Programs has re-energized efforts to persuade girls and young women to abstain from sexual activity or to use condoms (along with other forms of contraceptives) to prevent or reduce pregnancy as well as reduce their risk of getting STDs.19 Comprehensive sexuality education programs generally include one or more of the following components: (1) information about the benefits of abstinence, (2) information on the use of condoms and other contraceptive devices or methods for those who are sexually active, (3) information on the importance of early identification and treatment of sexually transmitted diseases, (4) information on how to resist negative peer pressure, and (5) information on how to improve communication skills (e.g., how to say no). Until recent legislation (P.L. 111-117 and P.L. 111-148), there was no federal funding stream that was exclusively for comprehensive sex education in schools. In other words, there was no federal appropriation specifically for comprehensive sex education. The following two programs, established in the 111th Congress, provide exclusive funding for comprehensive teen pregnancy prevention initiatives: (1) the Teen Pregnancy Prevention (TPP) program (funded at $110 million in FY2010) and (2) the Personal Responsibility Education Program (PREP; funded at $75 million in FY2010). Teen Pregnancy Prevention Program P.L. 111-117, the Consolidated Appropriations for FY2010, included a new discretionary TPP program that provides grants and contracts, on a competitive basis, to public and private entities to fund “medically accurate and age appropriate” programs that reduce teen pregnancy. Of the $110 million appropriated for the TPP program for FY2010, $75 million is for replicating programs that are proven through rigorous evaluation to be effective in reducing teenage pregnancy, behavioral factors underlying teen pregnancy, or other related risk factors; and $25 million is for research and demonstration grants. The TPP program is administered by the new Office of Adolescent Health within HHS. P.L. 111-117 also provides a separate $4.5 million (within the Public Health Service Act program evaluation funding) to carry out evaluations of teenage pregnancy prevention approaches. Personal Responsibility Education Program P.L. 111-148 (the Patient Protection and Affordable Care Act, PPACA) established a new state formula grant program and appropriated $375 million at $75 million per year for five years (FY2010-FY2014) to enable states to operate a new Personal Responsibility Education program, which is a comprehensive approach to teen pregnancy prevention that educates adolescents on both abstinence and contraception to prevent pregnancy and sexually transmitted diseases. It also provides youth with information on several adulthood preparation subjects (e.g., healthy relationships, adolescent development, financial literacy, parent-child communication, educational and career success, and healthy life skills). The new Personal Responsibility (...continued) 18 This report uses the term sexually transmitted diseases (STDs) rather than sexually transmitted infections (STIs). In the literature the terms are often used interchangeably. 19 The Centers for Disease Control and Prevention (CDC) estimates that approximately 19 million new infections occur each year, almost half of them among young people ages 15 to 24. Source: “Trends in Reportable Sexually Transmitted Disease in the United States, 2006,” November 13, 2007. Congressional Research Service 6 . Teenage Pregnancy Prevention: Statistics and Programs Education program is mandated to provide programs that are evidence-based, medically accurate, and age-appropriate. Also, the Adolescent Family Life (AFL) program, which has been in existence since 1981, was funded at $16.7 million. The FY2010 appropriation for the AFL program (P.L. 111-117) stipulated that the funds were to be exclusively used for comprehensive sex education-type programs. Evaluation of Comprehensive Sex Education Programs There have been numerous evaluations of comprehensive sex education programs, but most of them did not use a scientific approach with experimental and control groups—an approach that most analysts agree provides more reliable, valid, and objective information than other types of evaluations.20 A recent report by the National Campaign to Prevent Teen Pregnancy, however, highlighted five teen pregnancy prevention programs that were subjected to a random assignment, experimentally designed study.21 These five comprehensive sex education programs were found to be effective in delaying sexual activity, improving contraceptive use among sexually active teenagers, or preventing teen pregnancy. Many analysts and researchers agree that effective pregnancy prevention programs (1) convince teens that not having sex or that using contraception consistently and carefully is the right thing to do; (2) last a sufficient length of time (i.e., more than a few weeks); (3) are operated by leaders who believe in their programs and who are adequately trained; (4) actively engage participants and personalize the program information; (5) address peer pressure issues; (6) teach communication skills; and (7) reflect the age, sexual experience, and culture of young persons in the programs.22 The new Office of Adolescent Health (OAH) within the Department of Health and Human Services (HHS) coordinates adolescent health programs and initiatives across HHS related to adolescent health promotion and disease prevention. The new OAH (established in FY2010) supports multi-disciplinary projects focused on improving adolescent health, collects and disseminates information on adolescent health to health professionals and the general public, and works in partnership with other HHS agencies to support evidence-based approaches to improving the health of adolescents. OAH provides a list of 28 programs/initiatives/interventions that it deems to be effective and suitable for replication.23 20 Note that there also are many reasons why programs are not considered successful. For example, in some cases the evaluation studies are limited by methodological problems or constraints because the approach taken is so multilayered that researchers have had difficulty disentangling the effects of multiple components of a program. In other cases, the approach may have worked for boys but not for girls, or vice versa. In some cases, the programs are very small, and thereby it is harder to obtain significant results. In other cases, different personnel may affect the outcomes of similar programs. 21 The National Campaign to Prevent Teen Pregnancy, “Putting What Works To Work: Curriculum-Based Programs That Prevent Teen Pregnancy,” 2007. (The report only examined studies that had been published in 2000 or later.) 22 Ibid. 23 The list of the 28 programs can be found at http://www.hhs.gov/ash/oah/prevention/research/programs/index.html. Congressional Research Service 7 . Teenage Pregnancy Prevention: Statistics and Programs Abstinence Education Many argue that sexual activity in and of itself is wrong if the individuals are not married. Advocates of the abstinence education approach argue that teenagers need to hear a single, unambiguous message that sex outside of marriage is wrong and harmful to their physical and emotional health. These advocates contend that youth can and should be empowered to say no to sex. They argue that supporting both abstinence and birth control is hypocritical and undermines the strength of an abstinence-only message. They also cite research that indicates that teens who take virginity pledges to refrain from sex until marriage appear to delay having sex longer than those teens who do not make such a commitment. (One study found that teens who publicly promise to postpone sex until marriage refrain from intercourse for about a year and a half longer than teens who did not make such a pledge.)24 They further argue that abstinence is the most effective (100%) means of preventing unwanted pregnancy and sexually transmitted diseases, including HIV/AIDS.25 Until FY2010, three federal programs included funding that was exclusively for abstinence education: the Title V Abstinence Education Block Grant to states, the Community-Based Abstinence Education (CBAE) program, and the “prevention” component of the Adolescent Family Life (AFL) demonstration program.26 All of these programs were carried out by HHS. For FY2009, federal abstinence education funding totals $149.8 million: $37.5 million for the Title V Abstinence Education Block Grant to states; $94.7 million for the CBAE program (up to $10 million of which could be used for a national abstinence education campaign) and $4.5 million for an evaluation of the CBAE program; and $13.1 million for AFL abstinence education “prevention” demonstration projects.27 Title V Abstinence Education The Title V Abstinence Education Block Grant to states was authorized under P.L. 104-193 (the 1996 welfare reform law). The law provided $50 million per year for five years (FY1998FY2002; funded through June 30, 2009, by various legislative extensions) in federal funds specifically for the abstinence education program.28 The Title V Abstinence Education program is considered a mandatory program and is funded by mandatory spending. It is a formula grant program. State funding is based on the proportion of low-income children in the state compared to the national total. Funds must be requested by states when they solicit Title V Maternal and Child Health (MCH) block grant funds and must be used exclusively for teaching abstinence (pursuant to P.L. 104-193) and may not be utilized in conjunction with, or for any other purpose. 24 Peter S. Bearman and Hannah Bruckner, “Promising the Future: Virginity Pledges as They Affect the Transition to First Intercourse,” American Journal of Sociology, January 2001. 25 Those opposed to the abstinence-only education approach generally favor a comprehensive sex education approach, but also claim that abstinence-only programs often use medically inaccurate information regarding STDs, condoms, and other contraceptive devices. The Department of Health and Human Services (HHS) now requires grantees of abstinence education programs to sign written assurances in grant applications that the material/data they use are medically accurate. 26 For more information on these abstinence education programs, see CRS Report RS20873, Reducing Teen Pregnancy: Adolescent Family Life and Abstinence Education Programs, by Carmen Solomon-Fears. 27 Abstinence education funding totaled $79 million in FY2001, $100 million in FY2002, $115 million in FY2003, $135 million in FY2004, $168 million in FY2005, and $177 million in each of FY2006 through FY2008. 28 The Title V Abstinence Education Block Grant is a mandatory formula grant program (i.e., its funding is considered mandatory funding as opposed to discretionary funding). Congressional Research Service 8 . Teenage Pregnancy Prevention: Statistics and Programs To receive federal funds, a state must match every $4 in federal funds with $3 in state funds.29 This means that full funding (from states and the federal government) for abstinence education must total at least $87.5 million annually. In FY2008, 23 states and several territories chose not to sponsor a Title V Abstinence Education program. As mentioned above, the Title V Abstinence Education program was continued through a series of funding extensions. The program’s funding expired on June 30, 2009,30 but P.L. 111-148, the Patient Protection and Affordable Care Act (PPACA; enacted March 23, 2010), reauthorized the program and restored funding to the Title V Abstinence Education formula block grant to states at the previous annual level of $50 million for each of the years FY2010 through FY2014 ($250 million over five years). Community-Based Abstinence Education31 Additional abstinence-only education funding (discretionary funding), for the CBAE program, had been included in annual appropriations legislation. P.L. 106-246 appropriated an additional $20 million for abstinence education to HHS under the special projects of regional and national significance (SPRANS) program for FY2001 to bolster the abstinence-only message for adolescents ages 12 to 18. CBAE program competitive grants provided support to public and private entities for the development and implementation of abstinence-only education programs (that conform to the definition of abstinence education defined in the Title V Abstinence Education Block Grant to states) for adolescents ages 12 through 18, in communities nationwide. Funding for the CBAE program increased incrementally, from $20 million in FY2001 to $108.9 million in FY2008; in FY2009 CBAE funding dropped to $94.7 million. 32 No abstinence education funding was appropriated for FY2010 through the annual appropriations process (i.e., the CBAE program was not funded in FY2010).33 Moreover, from FY2004 through FY2009, $4.5 million annually (in discretionary funding) was set aside from the Public Health Service for evaluation of the CBAE program.34 Adolescent Family Life Program—“Prevention” Component The AFL demonstration program was enacted in 1981 as Title XX of the Public Health Service Act (P.L. 97-35). It is administered by the Office of Adolescent Pregnancy Programs at HHS. The purpose of the AFL program is to evaluate innovative and integrated approaches to the delivery of 29 States use a variety of methods to meet the federal matching requirement, such as state funds, private or foundation funds, matching funds from community-based grantees, and in-kind services (e.g., volunteer staffing and public service announcements). 30 As mentioned above, since its inception, the Title V Abstinence Education Block Grant has been funded at a rate of $50 million per year. Funding for the program expired on June 30, 2009. Thereby, federal funding for the program for FY2009 was $37.5 billion (i.e., a rate of $50 million per year for three-quarters of the fiscal year). 31 The CBAE program was known as the Special Projects for Regional and National Significance (SPRANS) until FY2005. The CBAE program was funded through Section 1110 of the Social Security Act for discretionary grants. 32 In the intervening years, the CBAE program was funded at $40 million in FY2002, 54.6 million in FY2003, $70 million in FY2004, $99.2 million in FY2005, $108.8 million in FY2006, and $108.9 million in FY2007. 33 Instead, P.L. 111-117, the Consolidated Appropriations for FY2010, includes a $110 million new discretionary teenage pregnancy prevention program for FY2010. 34 In FY2010, $4.5 million annually (in discretionary funding) was set aside from the Public Health Service for evaluation of the TPP program. Congressional Research Service 9 . Teenage Pregnancy Prevention: Statistics and Programs comprehensive services to pregnant and parenting adolescents, and provide and evaluate teenage pregnancy prevention services that promote abstinence from sexual activity for adolescents. The AFL program provides services to pre-adolescents, adolescents, families, infants of parenting teens, and teen fathers. Any public or private nonprofit organization or agency is eligible to apply for a demonstration grant. AFL projects can be funded for up to five years; all grantees are required to reapply each year of their continuing grant. Since 1998, the “prevention” component of the AFL demonstration program35 has been used to exclusively fund abstinence-only education projects that conform to the definition of abstinence education defined in the Title V Abstinence Education Block Grant to states. The “prevention” component of the AFL demonstration program was funded at $9.0 million in FY1998 and FY1999; $9.1 million in FY2000 and FY2001; $10.2 million in each of the fiscal years FY2002 through FY2004; and $13.1 million in each of the fiscal years FY2005 through FY2009. In FY2010, no funding was provided for the “prevention” component of the AFL program. Evaluation of Abstinence Education Programs A report by Mathematica Policy Research, Inc. (released in April 2007) presented the final results from a multi-year, experimentally based impact study on several abstinence-only block grant programs. 36 The report focused on four selected Title V abstinence education programs for elementary and middle school students. Based on follow-up data collected from youth (ages 10 to 14) four to six years after study enrollment, the report, among other things, presented the estimated program impacts on sexual abstinence and risks of pregnancy and STDs. According to the report Findings indicate that youth in the program group were no more likely than control group youth to have abstained from sex and, among those who reported having had sex, they had similar numbers of sexual partners and had initiated sex at the same mean age.... Program and control group youth did not differ in their rates of unprotected sex, either at first intercourse or over the last 12 months.... Overall, the programs improved identification of STDs but had no overall impact on knowledge of unprotected sex risks and the consequences of STDs. Both program and control group youth had a good understanding of the risks of pregnancy but a less clear understanding of STDs and their health consequences.37 In response to the report, HHS (under the Bush Administration) stated that the Mathematica study showcased programs that were among the first funded by the 1996 welfare reform law. It stated that its recent directives to states encouraged states to focus abstinence-only education programs 35 The AFL program authorizes grants for two types of demonstrations: (1) projects which provide “care” services (i.e., health, education, and social services to pregnant adolescents, adolescent parents, their infants, families, and male partners) to develop, test, and evaluate interventions with pregnant and parenting teens, in an effort to lessen the negative effects of childbearing on teen parents, their infants, and their families; and (2) projects which provide “prevention” services (i.e., services to promote abstinence from premarital sexual relations) to develop, test, and evaluate pregnancy prevention interventions designed to encourage adolescents to postpone sexual activity and reduce their risks for teenage pregnancy and STDs. The AFL demonstration program also has a basic and applied research component, the purpose of which is to report on the causes and consequences of adolescent premarital sexual relations, adolescent pregnancy, and adolescent parenting. 36 CRS Report RS22656, Scientific Evaluations of Approaches to Prevent Teen Pregnancy, by Carmen Solomon-Fears. 37 Christopher Trenholm, Barbara Devaney, Ken Fortson, Lisa Quay, Justin Wheeler, and Melissa Clark, “Impacts of Four Title V, Section 510 Abstinence Education Programs (final report),” Mathematica Policy Research, Inc., April 2007, http://aspe.hhs.gov/hsp/abstinence07/. Congressional Research Service 10 . Teenage Pregnancy Prevention: Statistics and Programs on youth most likely to bear children outside of marriage (i.e., high school students) rather than elementary or middle-school students. It also mentioned that programs need to extend the peer support for abstinence from the pre-teen years through the high school years.38 In contrast, a recently released study of the abstinence-only strategy found positive results. The scientifically based study assigned African-American students in the 6th and 7th grades to (1) an eight-hour abstinence-only intervention to reduce sexual intercourse; (2) an eight-hour safer sex intervention to increase condom use; (3) eight-hour and 12-hour comprehensive intervention to reduce sexual intercourse and/or increase condom use; or (4) a control group wherein an eighthour health promotion intervention was used to improve healthy behaviors unrelated to sexual behavior (i.e., informed students about behaviors associated with heart disease, hypertension, stoke, diabetes, and certain cancers). The study found that only about 34% of the student participants in the abstinence-only intervention said that they had engaged in sexual intercourse,39 whereas about 49% of the students in the control group reported (during the two-year follow-up interview) that they had engaged in sexual intercourse. 40 The authors also reported that among the participants in the abstinence-only intervention who had engaged in sexual activity during the demonstration, there was no significant difference between the abstinence-only intervention participants and the control group participants regarding consistent condom use. 41 The authors further noted that none of the interventions had significant effects on consistent condom use. 42 Youth Programs Youth programs incorporate elements of the other two approaches, and generally include one or more of the following components to address teen sexual activity: sex education, mentoring and counseling, health care, academic support, career counseling, crisis intervention, sports and arts activities, and community volunteer experiences. Youth programs receive funding from a wide array of sources, including the federal government, state and local governments, community organizations, private agencies, nonprofit organizations, and faith-based organizations. The sex education component of many youth programs usually includes an abstinence message (which is intended to enable teens to avoid pregnancy) along with discussions about the correct and consistent use of contraception (which is intended to reduce the risk of pregnancy for 38 U.S. Department of Health and Human Services (HHS), “Report Released on Four Title V Abstinence Education Programs,” HHS Press Office, April 13, 2007, http://aspe.hhs.gov/hsp/abstinence07/factsheet.shtml. 39 The participants were interviewed two years after the intervention. 40 John B Jemmott III, Loretta S. Jemmott, and Geoffrey T. Fong, “Efficacy of a Theory-Based Abstinence-Only Intervention Over 24 Months,” Archives of Pediatrics and Adolescent Medicine, v. 164, no. 2, February 2010, pp. 152159. (Note: The authors remarked that the abstinence-only intervention studied would not meet the federal criteria for an abstinence-only program. One difference between the abstinence-only intervention studied and the Title V Abstinence Education block grant program was that the target behavior of the intervention was to abstain from any form of sexual intercourse (vaginal, anal, or oral) until a time later in life when the adolescent is more prepared to handle the consequences of sex, whereas one of the necessary components of the federal abstinence-only education programs was to teach school-age children that they were expected to abstain from sexual activity until they got married.) 41 According to the study, 76% of the abstinence-only participants who had engaged in sexual activity had used condoms consistently during intercourse in the past three months, whereas 78% of the control group participants had used condoms consistently. 42 John B Jemmott III, Loretta S. Jemmott, and Geoffrey T. Fong, “Efficacy of a Theory-Based Abstinence-Only Intervention Over 24 Months,” Archives of Pediatrics and Adolescent Medicine, v. 164, no. 2, February 2010, p. 157. Congressional Research Service 11 . Teenage Pregnancy Prevention: Statistics and Programs sexually active teens). There is a significant difference between abstinence as a message and abstinence-only interventions. While some child advocates continue to support an abstinenceonly program intervention (with some modifications), others argue that an abstinence message integrated into a comprehensive sex education program that includes information on the use of contraceptives and that enhances decision-making skills is a more effective method to prevent teen pregnancy. A recent nationally representative survey found that 90% of adults and teens agree that young people should get a strong message that they should not have sex until they are at least out of high school, and that a majority of adults (73%) and teens (56%) want teens to get more information about both abstinence and contraception.43 The American public—both adults and teens—supports encouraging teens to delay sexual activity and providing young people with information about contraception. 44 Some youth programs seek to delay the first time teens have sex. Others have an underlying goal of trying to decipher the root reasons behind teen pregnancy and childbearing. Is it loneliness or trying to find love or a sense of family? Is it carelessness—not bothering with birth control or using it improperly—or shame—not wanting to go to the doctor to ask about birth control or not wanting to be seen in a pharmacy purchasing birth control? Is it a need to meet the sexual expectations of a partner? Is it trying to find individual independence or is it defiance (a mentality of you can’t boss me or control me—“I’m grown”)? Is it trying to validate and/or provide purpose to one’s life? Is it realistically facing the probability that the entry-level job she can get at the age of 18 is the same or similar to the one she will likely have when she is 30, thus why should she wait to have a child? In addition, many youth programs also want to prevent second or additional births to teens and they realize that a different approach may be needed to prevent secondary births as compared to first births. Research has indicated that youth programs that include mentoring components, enhanced case management, home visits by trained nurses and/or program personnel, and parenting classes have been effective in reducing subsequent childbearing by teens.45 Evaluation of Youth Programs A study that evaluated youth programs that sought to delay the first time teens have sex partly summarized the research by highlighting some characteristics or activities associated with teenagers who delayed sexual activity. The study reported that (1) teens who do well in school and attend religious services are more likely to delay sexual initiation; (2) girls who participate in sports also delay sex longer than those who do not; and (3) teens whose friends have high educational aspirations, who avoid such risky behavior as drinking or using drugs, and who 43 Bill Albert, “With One Voice 2007—America’s Adults and Teens Sound Off About Teen Pregnancy,” National Campaign to Prevent Teen Pregnancy, February 2007, p. 2., http://www.teenpregnancy.org/resources/data/pdf/ WOV2007_fulltext.pdf. 44 There appears to be significant public support for the involvement of religious groups in preventing teen pregnancy. When asked what organizations could do the best job of providing teen pregnancy prevention services, 39% said religious groups, 42% said non-religious community groups, and 12% said government. (Source: The National Campaign to Prevent Teen Pregnancy, Keeping the Faith: The Role of Religion and Faith Communities in Preventing Teen Pregnancy, by Barbara Dafoe Whitehead, Brian L. Wilcox, and Sharon Scales Rostosky. September 2001.) 45 Erin Schelar, Kerry Franzetta, and Jennifer Manlove, “Repeat Teen Childbearing: Differences Across States and by Race and Ethnicity,” Child Trends, Research Brief no. 2007-23, October 2007. Congressional Research Service 12 . Teenage Pregnancy Prevention: Statistics and Programs perform well in school are less likely to have sex at an early age than teens whose friends do not.46 Other Federal Programs to Reduce Teen Pregnancy Although there was not a federal comprehensive sex education program per se for teens until 2010, there were many federal programs that provided information about contraceptives, and provided referral and counseling services related to reproductive health. These programs still provide such services, they include the Title XX Adolescent Family Life “care” demonstration grants, Title X Family Planning, and Medicaid Family Planning. Also, funds from the Maternal and Child Health block grant, the Title XX Social Services block grant, the TANF block grant, and several other Department of Health and Human Services (HHS) programs47 can be used to provide contraceptive services to teens.48 The Adolescent Family Life (AFL) Program: Title XX of the Public Health Services Act The Adolescent Family Life (AFL) program, created in 1981 (Title XX of the Public Health Services Act), was the first federal program to focus on adolescents. The AFL Program was created in 1981 to support demonstration projects that provide comprehensive and innovative health, education, and social services to pregnant and parenting adolescents, their infants, male partners, and their families. The AFL program is authorized to provide comprehensive sex education information, including information about contraceptive methods (sometimes referred to as the AFL “care” component) as well as abstinence-only-focused educational information (sometimes referred to as the AFL “prevention” component). The AFL program also seeks to prevent subsequent births among teens. Although there are many federally funded programs that provide pregnancy prevention information and/or services to teens, 49 from 1981 to 1996, the Adolescent Family Life (AFL) program was the only federal program that was required to use all of its funding directly (and exclusively) on the issues of adolescent sexuality, pregnancy, and parenting. From 1998 to 2009, federal teen pregnancy prevention efforts relied heavily on using abstinence-only education as its primary tool. The federal appropriation for the AFL program for FY2010 stipulated that none of the funds were to be used to fund abstinence-only type projects. 46 Jennifer Manlove, Angela Romano Papillio, and Erum Ikramullah, “Not Yet: Program To Delay First Sex Among Teens,” The National Campaign to Prevent Teen Pregnancy and Child Trends, September 2004, p. 4. 47 For example, the mission of the CDC’s Division of Adolescent and School Health (DASH) is to prevent the most serious health risks among children, adolescents, and young adults. Such health risks include preventing unintended pregnancies among children, teens, and young adults. 48 U.S. General Accounting Office, “Teen Pregnancy: State and Federal Efforts to Implement Prevention Programs and Measure Their Effectiveness, GAO/HEHS-99-4, November 1998. (GAO is now known as the Government Accountability Office.) 49 These programs include the Adolescent Family Life (AFL) program, Medicaid Family Planning, Title X Family Planning, the Maternal and Child Health block grant, the Temporary Assistance for Needy Families (TANF) block grant, the Title XX Social Services block grant, and a couple of teen pregnancy prevention programs administered by the Centers for Disease Control and Prevention. Congressional Research Service 13 . Teenage Pregnancy Prevention: Statistics and Programs Reproductive Health and Family Planning Services: Title X of the Public Health Services Act The National Family Planning Program, created in 1970 as Title X of the Public Health Services Act, is administered through the Office of Population Affairs/Office of Public Health and Science, Department of Health and Human Services (HHS). It provides grants to public and private nonprofit agencies to provide voluntary family planning services for individuals who are otherwise ineligible for medical services. Family planning programs provide basic reproductive health services: contraceptive and infertility services, gynecological care, screening for breast and cervical cancers, STDs, reproductive health counseling/education and referrals. Maternal and Child Health (MCH) Block Grant: Title V of the Social Security Act These funds support a variety of health services for women and children, including adolescent pregnancy prevention activities. Activities include adolescent pregnancy prevention programs; state adolescent health coordinators; state prenatal hotlines; family planning; technical assistance and other prevention services. Through the block grants, approximately 610 school-based and school-linked centers are supported. Medicaid: Title XIX of the Social Security Act Medicaid is a jointly funded federal-state health insurance program for certain low-income people. The federal government pays 90% of state expenditures for Medicaid family planning services. The enhanced match encourages states to fund family planning programs that provide patient counseling and education on pregnancy prevention and reproductive health. Social Services Block Grant: Title XX of the Social Security Act The Social Services Block Grant is a flexible source of federal funds that states may use to support a range of social services, which may include family planning services and pregnancy prevention and parenting programs. Temporary Assistance for Needy Families (TANF): Title IV-A of the Social Security Act One of the four goals of the 1996 welfare reform law (P.L. 104-193) is to prevent and reduce outof-wedlock pregnancies.50 To receive assistance under TANF, unmarried minor parents are required to live at home or in an adult-supervised setting and to attend school if they lack a high school diploma. HHS also awarded a bonus of $20 million for each of the years FY1999-FY2006 to up to five states that showed the largest decrease in nonmarital births, while simultaneously maintaining abortion rates at or lower than FY1995 levels. P.L. 109-171 eliminated this bonus. 50 Although P.L. 104-193 uses pregnancies as the policy variable, in practice, births have become the indicator because birth data are more current and reliable than pregnancy data. Congressional Research Service 14 . Teenage Pregnancy Prevention: Statistics and Programs The National Strategy to Prevent Out-of-Wedlock Teen Pregnancies In January 1997, HHS announced the National Strategy to Prevent Out-of-Wedlock Teen Pregnancies in January 1997. The purpose of the National Strategy is to ensure that at least 25% of communities in the United States have pregnancy prevention programs. (Annual reports were published for 1997-1999.) An alternative initiative, which is part of the Strategy, encourages states to create Second Chance Homes with TANF and other funding. These homes are expected to provide teen parents, who might be at risk of abuse if they stayed at home, with guidance in parenting, child development, budgeting, health and nutrition; these skills are seen as a way to prevent repeat pregnancies. P.L. 104-193 contained some comprehensive child support enforcement measures. Because strict child support enforcement is thought to deter nonmarital childbearing, the child support provisions were seen by Congress as another method of attempting to reduce nonmarital pregnancies. Child support enforcement measures include streamlined efforts to name the father in every case; employer reporting of new hires (to locate noncustodial parents quicker); uniform interstate child support laws; computerized statewide collections to expedite payment; and stringent penalties, such as the revocation of a drivers’ license in cases in which noncustodial parents owe past-due child support. Author Contact Information Carmen Solomon-Fears Specialist in Social Policy csolomonfears@crs.loc.gov, 7-7306 Congressional Research Service 15about 17% in 2013.16 Financial and Social Costs of Teen Births Preventing teen pregnancy is generally considered a priority among policymakers and the public because of its high economic, social, and health costs for teen parents and their families. Teenage mothers and fathers tend to have less education and are more likely to live in poverty than their peers who are not teen parents. Children of teenage mothers are more likely than children of older mothers to have chronic medical conditions, rely heavily on provided health care, do poorly in school, give birth during their teen years (continuing the cycle of teen pregnancy), spend some time in a juvenile detention facility or jail, and be unemployed or underemployed as a young adult.17 Other data indicate that 30% of teen girls who have dropped out of high school cite pregnancy or parenthood as a reason, 67% of teen mothers who moved out of their own family’s household live below the poverty level, 63% of teen mothers receive some type of public benefits within the first year after their children are born, less than 25% of teen mothers receive any child support payments, and children born to mothers under age 18 score significantly worse on measures of school readiness including math and reading tests.18 Teen childbearing in the United States cost taxpayers (federal, state, and local) about $9.4 billion in 2010, according to an analysis by The National Campaign to Prevent Teen and Unplanned Pregnancy.19 According to the report, most of the costs of teen childbearing are associated with negative consequences for the children of teen mothers, including increased costs for health care, 14 Joyce A. Martin, Brady E. Hamilton, Michelle J.K. Osterman, Sally C. Curtin, and T.J. Mathews “Births: Final Data for 2013,” National Vital Statistics Reports, vol. 64, no. 1, January 15, 2015, Table A. 15 Ibid. 16 Ibid, Table 2. 17 Emily Holcombe, Kristen Peterson, and Jennifer Manlove, Ten Reasons to Still Keep the Focus on Teen Childbearing, Child Trends, March 2009. See also: Urban Institute, Kids Having Kids: Costs and Social Consequences of Teen Pregnancy, edited by Saul D. Hoffman and Rebecca A. Maynard, 2008 (second edition). 18 The National Campaign to Prevent Teen and Unplanned Pregnancy, Why It Matters: Teen Childbearing, Education, and Economic Wellbeing, July 2012. 19 The National Campaign to Prevent Teen and Unplanned Pregnancy, Counting It Up—The Public Cost of Teen Childbearing: Key Data, December 2013. (This analysis updates research originally conducted by Saul Hoffman, of the University of Delaware, and released by the National Campaign to Prevent Teen Pregnancy in 2006.) Congressional Research Service 4 Teenage Pregnancy Prevention: Statistics and Programs child welfare, incarceration, and lost tax revenue. The study looks only at the increase in these costs that is associated with having a child before age 20 versus having a child at age 20 or 21. That is, they are net costs and not gross costs.20 The December 2013 study by the National Campaign to Prevent Teen Pregnancy estimated that in 2010, adolescent childbearing cost U.S. taxpayers about $9.4 billion per year: $3.1 billion in child welfare benefits; $2.1 billion in public sector health care expenses; $2.0 billion in spending on incarceration (for the sons of women who had children as adolescents); and $2.2 billion in lost tax revenue because of lower earnings of children of teen mothers over their own adult lifetimes. Research indicates that teens who give birth are less likely to complete high school and go on to college, thereby reducing their potential for economic self-sufficiency. The research also indicates that the children of teens are more likely than children of older parents to experience problems in school and drop out of high school, and as adults are more likely to repeat the cycle of teenage pregnancy and poverty. The 2013 report contends that if the teen birth rate had not declined between 1991 and 2010, the annual costs associated with teen childbearing would have been about $21 billion (instead of $9.4 billion).21 Reasons for High Pregnancy and Birth Rates Among Teens In 2013, 30.0% of 9th graders reported having experienced sexual intercourse. The corresponding statistics for older teens were 41.4% for 10th graders, 54.1% for 11th graders, and 64.1% for 12th graders.22 The high volume of pregnancies and birth rates among teenagers is associated with earlier sexual activity among teen girls. Also, beginning in about 2004, the use of contraception (which was never as high as the use in other developed countries) started waning.23 The academic and professional communities also maintain that teen parenthood is one of the negative consequences of growing up without a father.24 The president of the Alan Guttmacher Institute, commenting on a study about adolescent pregnancy and childbearing in “developed” countries, stated: “In the United States, poverty and inequity clearly are behind much of our high rates of pregnancy, birth and abortion. But lack of sensitive, confidential, low-cost contraceptive services and the denial of accurate and frank information about sex, are equally to blame.”25 Other commentators argue that 20 The costs discussed by the study include those associated with all children in a given year who had been born to a teen mother—this includes very young children as well as those who are currently adolescents or young adults. 21 The National Campaign to Prevent Teen and Unplanned Pregnancy, Counting It Up—The Public Cost of Teen Childbearing: Key Data, December 2013. 22 Centers for Disease Control and Prevention, “Youth Risk Behavior Surveillance—United States, 2013,” MMWR, vol. 63, no.4, June 13, 2014, p. 112 (Table 63). 23 John S. Santelli and Andrea J. Melnikas, “Teen Fertility in Transition: Recent and Historic Trends in the United States,” Annual Review of Public Health 2010, vol. 31, pp. 375-376. 24 Wendy Sigle-Rushton and Sara McLanahan, Father Absence and Child Well-Being: A Critical Review, Princeton University, Center for Research on Child Wellbeing (Working Paper #02-20), November 2002. 25 Alan Guttmacher Institute, United States and the Russian Federation Lead the Developed World in Teenage Pregnancy Rates, News Release, February 24, 2000, p. 2. Congressional Research Service 5 Teenage Pregnancy Prevention: Statistics and Programs teen childbearing is so high in the United States because of underlying social and economic problems. It reflects a decision among a set of girls to “drop-out” of the economic mainstream; they choose non-marital motherhood at a young age instead of investing in their own economic progress because they feel they have little chance of advancement.26 Decline in Pregnancy/Birth Rates One reason given for the historical decline (1991-2005) in teen pregnancies and births is that sexually active female teenagers had significantly increased their use of contraceptives, particularly condoms. Abstinence campaigns, aimed at younger teens, were also seen as having a positive effect on pregnancy prevention. Moreover, casual sex, which may increase the risk of sexually transmitted diseases (STDs) and may prove to be fatal given the presence of HIV/AIDS, is viewed in an increasingly negative light by many teenagers. In 2006 and 2007, the decline in the teen birth rate was interrupted by a small increase. According to a 2008 report: A dearth of research examining the factors responsible for previous trends undermines our ability to understand what may be occurring at present. Hypotheses abound, including changes in the economy, attitudes, anxiety, schooling, public policy, programs and services, families, and media messages. In addition, prevention fatigue and the need for new strategies to reach teens who have not been reached by existing approaches have also been suggested.27 Some observers attribute the return to the long-term downward trend in teen birth rates (after the two-year increase in 2006 and 2007) to the severe recession that began in 2008. They contend that the decrease in teen births—like the decrease in overall births—is, in part, because teenagers are being more careful as they witness the economic difficulties faced by their families.28 According to the Center for Disease Control and Prevention (CDC): The impact of strong pregnancy prevention messages directed to teenagers has been credited with the birth rate declines. Recently released data from the National Survey of Family Growth, conducted by the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS), have shown increased use of contraception at first initiation of sex and use of dual methods of contraception (that is, condoms and hormonal methods) among sexually active female and male teenagers. These trends may have contributed to the recent birth rate declines.29 According to one commentator, several factors have been discussed among researchers as reasons underlying the falling teen birth rate during the period since 2007. Some of these factors include (1) the recession that started in late 2007 and ended in the middle of 2009; (2) the slight increase in IUD use; (3) the popular MTV show that deglamorized teen pregnancy; (4) the use of the Plan 26 Kearney and Levine, “Why is the teen birth rate in the United States so high and why does it matter?” Journal of Economic Perspectives, Spring: 26(2), 2012, pp. 141-166. 27 The National Campaign to Prevent Teen and Unplanned Pregnancy and Child Trends, Teen Births: Examining the Recent Increase, by Kristin Anderson Moore, October 2008, p. 1. 28 Rob Stein, “Birthrate Among Teens Hits Record Low,” Washington Post, December 22, 2010, A02. 29 Brady E. Hamilton and Stephanie J. Ventura, “Birth Rates for U.S. Teenagers Reach Historic Lows for All Age and Ethnic Groups,” NCHS Data Brief, no. 89, April 2012, p. 5. Congressional Research Service 6 Teenage Pregnancy Prevention: Statistics and Programs B “morning after” pill; and (5) increased use of the Internet via iPhones which allow teenagers immediate access to information they may have been too embarrassed to ask parents or other adults.30 There is not agreement among researchers regarding which of and to what extent the aforementioned factors contributed to the 36% reduction in teen births since 2007. Other interested parties maintain that “with improved economic opportunities, reduced poverty, and improved prospects for other adult outcomes, teen pregnancy would also decline.”31 They assert that public policies targeted directly at teen pregnancy prevention such as sex education, improved access to contraception, and abstinence counseling are not likely to improve outcomes much for disadvantaged young women.32 Federal Strategies to Reduce Teen Pregnancy Reducing nonmarital pregnancies is one of the explicit goals that were stipulated in the 1996 welfare reform law (P.L. 104-193). The 1996 welfare reform law also provided funding for and spearheaded the abstinence-only approach for preventing and reducing teen pregnancy. Although the pregnancy rate, birth rate, and abortion rate for teens have all dropped in recent years, the teen birth rate in the United States is still far above that of most industrialized countries. The U.S. teen birth rate was one and one-half times that of the United Kingdom and nearly seven times that of Japan and Denmark. In 2012, teen birth rates were 4.3 births per 1,000 teens ages 15-19 in Japan, 4.4 births per 1,000 teens ages 15-19 in Denmark; 8.0 per 1,000 in Germany; 14.1 per 1,000 in Canada (2009 data); 19.8 per 1,000 in the United Kingdom; and 29.4 per 1,000 in the United States.33 Until recently, there was a great divide in the teen pregnancy prevention arena with one group maintaining that “abstinence-only education” programs (sometimes referred to as sexual risk avoidance programs) are the best and healthiest strategy to prevent unintended teen pregnancies and sexually transmitted infections among teenagers34 (see “1996-2009: Abstinence Only” section below for additional arguments). The other group claims a comprehensive approach to sex education provides today’s youth with the information and decision-making skills needed to make realistic, practical decisions about whether to engage in sexual activities. They contend that such an approach allows young people to make informed decisions regarding abstinence, gives them the information they need to set relationship limits and to resist peer pressure, and also provides them with information on the use of contraceptives and the prevention of sexually transmitted 30 Sarah Kliff, The mystery of the falling teen birth rate, September 22, 2014 (updated January 21, 2015)— http://www.vox.com/2014/8/20/5987845/the-mystery-of-the-falling-teen-birth-rate. 31 Melissa S. Kearney and Phillip B. Levine, “Why is the Teen Birth Rate in the United States So High and Why Does It Matter?,” Journal of Economic Perspectives, vol. 26, no. 2 (Spring 2012), p. 163. 32 Ibid. 33 United Nations Statistics Division, “Demographic Yearbook 2013,” http://unstats.un.org/unsd/demographic/products/ dyb/dyb2013/Table10.pdf, Table 10. See also “Adolescent Pregnancy and Childbearing: Levels and Trends in Developed Countries,” by Susheela Singh and Jacqueline E. Darroch, Family Planning Perspectives, Alan Guttmacher Institute, vol. 3, no. 1, January/February 2000, pp. 14-23. 34 U.S. House of Representatives, Committee on Energy and Commerce, The Policy Paper Series: Transforming Ideas Into Solutions, vol. 1, issue 2, “A Better Approach to Teenage Pregnancy Prevention-Sexual Risk Avoidance,” prepared by the Energy and Commerce Committee Majority Staff, July 2012. Congressional Research Service 7 Teenage Pregnancy Prevention: Statistics and Programs diseases.35 Given that 47.4% (2011 data) of high school students have experienced sexual intercourse, advocates argue that abstinence-only messages provide no protection against the risks of pregnancy and disease for these youth. They further point out that according to one study, teens who break their virginity pledges were less likely to use contraception the first time than teens who had never made such a promise.36 In addition, the high number of females under age 25 with sexually transmitted infections (STIs)37 has re-energized efforts to persuade girls and young women to abstain from sexual activity or to use condoms (along with other forms of contraceptives) to prevent or reduce pregnancy and reduce their risk of getting STIs.38 A nationally representative survey conducted in 2012 found that (1) 93% of adults and 87% of teens agree that young people should get a strong message that they should not have sex until they are at least out of high school, and (2) a majority of adults (74%) and many teens (49%) want teens to get more information about both abstinence and contraception. Specifically with regard to federally funded programs, 62% of parents of teens indicated that teens should be provided with information about both postponing sex and about birth control or protection.39 The American public—both adults and teens—support encouraging teens to delay sexual activity and providing young people with information about contraception.40 They see encouraging teens to delay sex and providing teens with information about contraception as complementary, not contradictory strategies. In 2010, HHS Secretary Kathleen Sebelius stated: “Teen pregnancy is a serious national problem and we need to use the best science of what works to address it. This investment will help bring evidence-based initiatives to more communities across the country while also testing new approaches so we can expand our toolkit of effective interventions.”41 The CDC has identified teen pregnancy prevention as a winnable battle. According to the CDC: Through our experience, we know that we can prevent teen pregnancies by promoting teenfriendly interventions aimed at both increasing the number of teens who abstain from or delay sexual activity, and increasing the number of sexually active teens who consistently 35 Some contend that the abstinence-only approach leads to a substitution of other risky behaviors such as oral sex. They cite data that indicate that about 25% of virgin teens ages 15 through 19 have engaged in oral sex; Child Trends Data Bank, “New Indicator on Oral Sex,” September 15, 2005, at http://www.childtrendsdatabank.org/whatsNew.cfm. 36 Peter S. Bearman and Hannah Bruckner, “Promising the Future: Virginity Pledges as They Affect the Transition to First Intercourse,” American Journal of Sociology, January 2001. 37 This report uses the term sexually transmitted diseases (STDs) and sexually transmitted infections (STIs) interchangeably. 38 A Centers for Disease Control and Prevention (CDC) report indicated that approximately 19 million new sexually transmitted infections occur each year, almost half of them among young people ages 15 to 24; “Trends in Reportable Sexually Transmitted Disease in the United States, 2007,” January 5, 2009. 39 Bill Albert, With One Voice 2012—America’s Adults and Teens Sound Off About Teen Pregnancy, National Campaign to Prevent Teen Pregnancy and Unplanned Parenthood, August 2012, pp. 17-19, http://thenationalcampaign.org/sites/default/files/resource-primary-download/wov_2012.pdf. 40 There appears to be significant public support for the involvement of religious groups in preventing teen pregnancy. In the survey associated with the “With One Voice report,” adults (73%) and teens (75%) agreed that religious leaders and groups should be doing more to help prevent teen pregnancy. (Source: Bill Albert, With One Voice 2012— America’s Adults and Teens Sound Off About Teen Pregnancy, National Campaign to Prevent Teen Pregnancy and Unplanned Parenthood, August 2012, p. 38, http://thenationalcampaign.org/sites/default/files/resource-primarydownload/wov_2012.pdf.) 41 U.S. Department of Health and Human Services, HHS awards evidence-based teen pregnancy prevention grants, news release, September 30, 2010. Congressional Research Service 8 Teenage Pregnancy Prevention: Statistics and Programs and correctly use effective contraceptive methods. This can be accomplished by involving more teens in evidence-based programs and linking prevention programs to clinical services.42 The following section examines federal strategies to reduce teen pregnancy by focusing on three time periods: 1981-1996, 1996-2009, and 2009 to the present. 1981-1996: Reducing Pregnancies and Helping Adolescent Mothers The Adolescent Family Life (AFL) program (Title XX of the Public Health Service Act), created in 1981, was the first federal program to focus on adolescents. From 1981 to 1996, the AFL program was the only federal program that was required to use all of its funding directly (and exclusively) on the issues of adolescent sexuality, pregnancy, and parenting. The AFL program authorized grants for three types of demonstrations: (1) projects that provide “care” services only (i.e., health, sex education information, including information about contraceptive methods, and social services to pregnant adolescents, adolescent parents, and their infants, families, and male partners);43 (2) projects that provide “prevention” services only (i.e., services to promote abstinence from premarital sexual relations, including abstinence-onlyfocused educational information, for pre-teens, teens, and their families); and (3) projects that provide a combination of care and prevention services. It is important to note that until 1998, the “prevention” services component of the AFL program offered a wide range of interventions, including contraception services, to help young people avoid pregnancy. It was only after implementation of the Title V Abstinence Education block grant to states (discussed later) that Congress mandated that AFL “prevention” demonstration grants were only to be awarded for programs that used an abstinence-only model (that adhered to the abstinence definition used by the Title V Abstinence Education program). The AFL program also provided funding for research grants dealing with various aspects of adolescent sexuality, pregnancy, and parenting. Through its research component, the AFL program attempted to increase understanding of how to prevent adolescent pregnancies and their adverse consequences. Research projects have included studies that examined the causes and consequences of adolescent sexual relations, the use of contraceptives, the impact of pregnancy on adolescents, and child-rearing practices of adolescents. (The AFL program is described in greater detail later in this report.) 42 Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Dear Colleague Letter by Thomas R. Frieden, Director, Centers for Disease Control and Prevention, January 14, 2011. 43 These care services projects are synonymous to what is now generally referred to as comprehensive sex education. Comprehensive sex education programs generally include one or more of the following components: (1) information about the benefits of abstinence, (2) information on the use of condoms and other contraceptive devices or methods for those who are sexually active, (3) information on the importance of early identification and treatment of sexually transmitted diseases, (4) information on how to resist negative peer pressure, and (5) information on how to improve communication skills (e.g., how to say no). Congressional Research Service 9 Teenage Pregnancy Prevention: Statistics and Programs 1996-2009: Abstinence Only When the idea of abstinence-only education was being discussed during the 1994-1996 welfare reform debate, it was in the context of providing funding for abstinence education that was equal to amounts provided then for programs which, among other things, provided information about contraception and sexually transmitted diseases and sometimes referrals or access to contraception services to teenagers. From 1996 through 2009, federal teen pregnancy prevention efforts relied heavily on using abstinence-only education as the primary tool. Many commentators argued then (and now) that sexual activity in and of itself is wrong if the individuals are not married. Advocates of the abstinence education approach argue that teenagers need to hear a single, unambiguous message that sex outside of marriage is wrong and harmful to their physical and emotional health. These advocates contend that youth can and should be empowered to say no to sex. They argue that supporting both abstinence and birth control is hypocritical and undermines the strength of an abstinence-only message. They also cite research that indicates that teens who take virginity pledges to refrain from sex until marriage appear to delay having sex longer than those teens who do not make such a commitment. (One study found that teens who publicly promise to postpone sex until marriage refrain from intercourse for about a year and a half longer than teens who did not make such a pledge.)44 They further argue that abstinence is the most effective means (i.e., 100%) of preventing unwanted pregnancy and sexually transmitted diseases, including HIV/AIDS.45 Until FY2010, three federal programs included funding that was exclusively for abstinence education: the Title V Abstinence Education Block Grant to states, the Community-Based Abstinence Education (CBAE) program, and the “prevention” component of the Adolescent Family Life (AFL) demonstration program. All of these programs were carried out by HHS and are discussed in detail, later in this report. 2009-Present: Evidence-Based Until legislation passed in 2010 (P.L. 111-117 and P.L. 111-148), there was no federal funding stream exclusively for teen pregnancy prevention initiatives that included an array of intervention approaches including both abstinence-only and contraception information/services. The following two programs, established in the 111th Congress, provide federal funding for evidence-based teen pregnancy prevention initiatives: (1) the discretionary spending Teen Pregnancy Prevention (TPP) program and (2) the mandatory spending Personal Responsibility Education Program (PREP). These programs and their funding levels are discussed in detail in a later section of this report. 44 Peter S. Bearman and Hannah Bruckner, “Promising the Future: Virginity Pledges as They Affect the Transition to First Intercourse,” American Journal of Sociology, January 2001. 45 Those opposed to the abstinence-only education approach generally favor a comprehensive sex education approach, but also claim that abstinence-only programs often use medically inaccurate information regarding STDs, condoms, and other contraceptive devices. The Department of Health and Human Services (HHS) now requires grantees of abstinence education programs to sign written assurances in grant applications that the material/data they use are medically accurate. Congressional Research Service 10 Teenage Pregnancy Prevention: Statistics and Programs It appears that a consensus is now growing around the viewpoint that success in the teen pregnancy prevention arena does not necessarily have to be an “either-or” proposition in which “abstinence-only education” programs (sometimes referred to as sexual risk avoidance programs) are pitted against “comprehensive sex education” programs (sometimes referred to as sexual risk reduction programs). The Obama Administration has indicated that it will use evidence-based approaches to expand programs that work and eliminate programs that do not work. The Obama Administration is supportive of using rigorous evaluation (i.e., a scientific method using experimental and control groups) to determine whether untested innovative programs are effective.46 As discussed later, the Department of Health and Human Services (HHS) has compiled a list of 31 evidence-based program models that it has found to be effective in delaying sexual activity, increasing condom or contraception use for sexually active youth, or reducing teen pregnancy. This list includes many programs designed to educate youth on both abstinence and contraception for the purpose of preventing teen pregnancy. It also includes a couple of programs that many would consider abstinence-only education programs.47 The evidence-based approach to teen pregnancy prevention holds the view that whatever services or program components that are proven to be effective should be replicated or expanded upon by entities seeking federal dollars to prevent pregnancy among young people. Evidence-based teen pregnancy prevention programs are varied and approach the problem from different frameworks. Some teen pregnancy prevention programs seek to delay the first time teens have sex. Others have an underlying goal of trying to decipher the root reasons behind teen pregnancy and childbearing. Is it loneliness or trying to find love or a sense of family? Is it carelessness (not bothering with birth control or using it improperly), or shame (not wanting to go to the doctor to ask about birth control or not wanting to be seen in a pharmacy purchasing birth control)? Is it a need to meet the sexual expectations of a partner? Is it trying to find individual independence or is it defiance (a mentality of “you can’t boss me or control me—I’m grown”)? Is it trying to validate and/or provide purpose to one’s life? Is it realistically facing the probability that the entry-level job she can get at the age of 18 is the same or similar to the one she will likely have when she is 30, thus why should she wait to have a child? In addition, the purpose of several teen pregnancy prevention programs is to prevent second or additional births to teens. The more successful of such programs recognize that a different approach is often needed to prevent secondary births as compared to first births. Research has indicated that teen pregnancy prevention programs that include mentoring components, enhanced case management, home visits by trained nurses and/or program personnel, and parenting classes have been effective in reducing subsequent childbearing by teens.48 According to The National Campaign to Prevent Teen and Unplanned Pregnancy: 46 Ron Haskins and Jon Baron, Part 6: The Obama Administration’s Evidence-Based Social Policy Initiatives: An Overview, Coalition for Evidence-Based Policy http://www.brookings.edu/~/media/Files/rc/articles/2011/ 04_obama_social_policy_haskins/04_obama_social_policy_haskins.pdf. 47 The list of 31 evidence-based models includes several programs that are considered abstinence-only interventions: (1) Promoting Health Among Teens! Abstinence Only Intervention; (2) Adult Identity Mentoring (Project AIM); and (3) Making a Difference! 48 Erin Schelar, Kerry Franzetta, and Jennifer Manlove, “Repeat Teen Childbearing: Differences Across States and by Race and Ethnicity,” Child Trends, Research Brief no. 2007-23, October 2007. Congressional Research Service 11 Teenage Pregnancy Prevention: Statistics and Programs Most researchers agree that evidence-based teen pregnancy prevention programs share some common characteristics: • They have a strong theoretical underpinning that has both guided program development and informed the evaluation. Using theory helps program developers focus on specific risk and protective factors, which in turn strengthens their chances of changing behavior related to teen pregnancy. • They have been rigorously evaluated (that is, the evaluation tracked both implementation and outcomes, was based on randomized controlled trials or quasi-experimental methods, included adequate sample size and follow-up, addressed issues of retention/attrition, and used appropriate statistical analyses to control for confounding factors; some would add replication in multiple sites). • They change behavior—outcomes typically include delaying sex, increasing contraceptive use among sexually active teens, reducing the number of sexual partners, or reducing teen pregnancy itself. While positive changes in knowledge, attitudes, and behavioral intent are also encouraging, these outcomes are not as strongly tied to preventing teen pregnancy. • The evaluation results have been published in peer reviewed journals.49 The National Campaign to Prevent Teen and Unplanned Pregnancy also has stated the following: In the ongoing debate over teen pregnancy prevention, some of these characteristics have been called into question. We believe that it is important to clarify that different programmatic approaches can be grounded in different theories of behavior change. That is, there is no single valid theory. To suggest that a program is not theory-based because one does not agree with the theory or the approach is simply inaccurate. It is also inaccurate to suggest that one approach is more effective because of its underlying theory—effectiveness is an empirical question that needs to be tested by looking at the results of the program. Similarly, it is not valid to compare a theory to a proven intervention.50 Federal Teen Pregnancy Prevention Programs51 Teen Pregnancy Prevention (TPP) Program P.L. 111-117, the Consolidated Appropriations Act, FY2010, provided funding for a new discretionary TPP program that provides grants and contracts, on a competitive basis, to public and private entities to fund “medically accurate and age appropriate” programs that reduce teen pregnancy and for the federal costs associated with administering and evaluating such grants and contracts. The TPP program is administered by the Office of Adolescent Health in the Office Assistant Secretary for Health in the Department of Health and Human Services (HHS). 49 The National Campaign to Prevent Teen and Unplanned Pregnancy, Policy Brief: Key Points About Teen Pregnancy Prevention, December 2012, p. 3. 50 Ibid. 51 See the Appendix for a funding history of the programs discussed in this section of the report. Also see The National Campaign to Prevent Teen and Unplanned Pregnancy, Federal Funding Streams for Teen Pregnancy Prevention, March 2014. Congressional Research Service 12 Teenage Pregnancy Prevention: Statistics and Programs The following types of entities are eligible to apply for TPP program funding: nonprofit organizations, for-profit organizations, universities/colleges, research institutions, hospitals, community-based organizations, faith-based organizations, Indian tribes and tribal organizations, state/local governments, and small businesses. Of the $110 million appropriated for the TPP program for FY2010, $75 million was for “Tier 1” grants to replicate programs that had been proven through rigorous evaluation to be effective in reducing teenage pregnancy, behavioral factors underlying teen pregnancy, or other related risk factors;52 $25 million was for “Tier 2” grants for research and demonstration projects; and $10 million was for training and technical assistance, outreach, and other program support. P.L. 111117 also provided a separate $4.5 million for FY2010 (within the Public Health Service Act program evaluation funding) to carry out evaluations of TPP program approaches. Within the TPP program, “Tier 1” grants are available on a competitive basis for two broad program types: (1) curriculum-based programs that seek to educate young people about topics such as responsible behavior, relationships, and pregnancy prevention; and (2) youth development programs that seek to reduce teenage pregnancy and a variety of risky behaviors through a broad range of approaches. Youth development programs usually incorporate multiple components, such as service learning, academic support, or opportunities to participate in sports or the arts. They also collaborate with multiple networks and/or provide youth with development-focused activities. In both cases, funding under this announcement can only be provided to applicants who seek to replicate evidence-based programs that have been shown to reduce teenage pregnancy, behavioral risk factors underlying teenage pregnancy, or other associated risk factors.53 In most cases the Tier 1 grants must replicate an evidence-based program model that has been deemed by HHS to be effective.54 “Tier 2” grants are available on a competitive basis for research and demonstration grants to develop, replicate, refine, and test additional models and innovative strategies for preventing teenage pregnancy.55 Since its inception in FY2010, TPP program funding has ranged from a high of $110 million in FY2010 to a post-sequester56 low of $98.4 million in FY2013. Funding for TPP program 52 Under a contract with HHS, Mathematica Policy Research conducted an independent, systematic review of the evidence base. This review defined the criteria for the quality of an evaluation study and the strength of evidence for a particular intervention. Based on these criteria, HHS has defined a set of rigorous standards an evaluation must meet in order for a program to be considered effective. HHS has compiled a list of 31 evidence-based program models that it has deemed to have met those standards. (The 31 evidence-based programs can be found at http://www.hhs.gov/ash/ oah/oah-initiatives/teen_pregnancy/db/programs.html. 53 U.S. Department of Health and Human Services (HHS), Office of Public Health and Science, Office of Adolescent Health, Teenage Pregnancy Prevention: Replication of Evidence-based Programs, Funding Opportunity Announcement and Application Instructions, 2010. 54 If an applicant for a Tier 1 TPP program grant wants to apply to replicate a program model that is not on the HHS list of 31 evidence-based models, it may do so only if it is able to meet stringent specified criteria. Such applicants may be more successful if they submit applications for the Tier 2 TPP program for the teen pregnancy prevention research and demonstration grants. 55 U.S. Department of Health and Human Services (HHS), Office of Public Health and Science, Office of Adolescent Health & Administration for Children and Families, Administration on Children, Youth and Families, Teenage Pregnancy Prevention (TPP): Research and Demonstration Programs and Personal Responsibility Education Program (PREP), Funding Opportunity Announcement and Application Instructions, 2010. 56 The American Taxpayer Relief Act (ATRA, P.L. 112-240), enacted on January 2, 2013, made a number of significant changes to the procedures in the Budget Control Act of 2011 (BCA, P.L. 112-25). BCA, which included (continued...) Congressional Research Service 13 Teenage Pregnancy Prevention: Statistics and Programs evaluation was $4.5 million in FY2010 and $4.4 million in FY2011 and was increased to $8.5 million for each of the years FY2012 through FY2014. (See the Appendix for a funding history of the TPP program.) P.L. 113-76, the Consolidated Appropriations Act, 2014, enacted January 17, 2014, included funding of $101 million for the TPP program for FY2014. It also included funding of $8.5 million for program evaluation for FY2014.57 Pursuant to P.L. 113-164 (the Continuing Appropriations Resolution, 2015; enacted September 19, 2014), for FY2015 the TPP program was funded at the FY2014 rate of $101 million (plus $8.5 million for program evaluation) through December 11, 2014, or enactment of applicable appropriations legislation. Pursuant to P.L. 113-235 (the Consolidated and Further Continuing Appropriations Act, 2015; enacted December 16, 2014), the TPP program is funded at $101 million for FY2015 (plus $6.8 million for program evaluation). Personal Responsibility Education Program P.L. 111-148 (the Patient Protection and Affordable Care Act, ACA) established a new state formula grant program and appropriated $375 million at $75 million per year (mandatory spending) for five years (FY2010 through FY2014)58 to enable states to operate a new Personal Responsibility Education Program (PREP), which is a broad approach to teen pregnancy prevention that educates adolescents on both abstinence and contraception to prevent pregnancy and sexually transmitted diseases. It also provides youth with information on several adulthood preparation subjects (e.g., healthy relationships, adolescent development, financial literacy, parent-child communication, educational and career success, and healthy life skills). P.L. 113-93 (the Protecting Access to Medicare Act of 2014), which was enacted on April 1, 2014, extended PREP ($75 million per year) through FY2015 (i.e., September 30, 2015). A total of 59 jurisdictions are eligible for PREP. Eligible entities include all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, the Northern Mariana Islands, the Federated States of Micronesia, the Marshall Islands, and Palau. PREP funds do not require a state match. PREP is administered by the Administration on Children, Youth and Families’ (ACYF) Family and Youth Services Bureau (FYSB) in HHS. PREP contains five components: (1) state PREP formula grants, (2) competitive PREP grants, (3) Tribal PREP, (4) PREP–Innovative Strategies (PREIS), and (5) funding for training, technical assistance, and evaluation.59 (...continued) sequestration of most programs, projects, and activities included in the budget, was implemented on March 1, 2013. The sequestration of funds was ultimately applied at the program, project, and activity level within each account. 57 For additional information on the TPP program, see the following webpage: http://thenationalcampaign.org/sites/ default/files/resource-primary-download/overview_fedfunding.pdf. 58 PREP also was subject to sequestration. The FY2013 post-sequester operating level for PREP was $71.2 million in FY2013. The FY2014 post-sequester operating level for PREP is $69.6 million in FY2014. 59 U.S. Department of Health and Human Services, Justification of Estimates for Appropriations Committees, HHS, Administration for Children and Families, FY2015, pp. 339-340. Congressional Research Service 14 Teenage Pregnancy Prevention: Statistics and Programs Most of the PREP appropriation (about $55.250 million annually) goes to states/territories (via a formula grant based on youth population). The formula for determining the PREP allocation to states and territories is derived by calculating the proportion of the number of youth between the ages of 10 and 19 of a state to the total number of youth between the ages of 10 and 19 in all of the states and territories. A state/territory’s application for PREP funding must include a description of the state’s plan for using the allotment to achieve stipulated goals especially among youth populations that are the most high-risk or vulnerable for pregnancies or otherwise have special circumstances, including youth in foster care, homeless youth, youth with HIV/AIDS, pregnant youth who are under age 21, mothers who are under age 21, and youth residing in areas with high birth rates for youth.60 Currently 45 states, the District of Columbia, the Federated States of Micronesia, Puerto Rico, and the Virgin Islands receive PREP formula grant funds.61 If a state or territory failed to submit an application in FY2010 or FY2011, the state/territory was ineligible to apply for funds from the amounts allotted to the state or territory for each of FY2012, FY2013, and FY2014. Funds that would have gone to those jurisdictions for fiscal years 2010 through 2014 were used to award competitive three-year grants to local organizations and entities for the same purpose and in the same geographic regions.62 An organization or entity awarded such a grant must agree to participate in a rigorous federal evaluation. The first two components of PREP mentioned above (i.e., the state formula grant and the state competitive grant) are defined as programs designed to educate adolescents on both abstinence and contraception for the prevention of pregnancy and sexually transmitted infections, including HIV/AIDS, and at least three of the six stipulated adulthood preparation subjects. These two components of PREP also are required by law to replicate effective evidence-based programs or substantially incorporate elements of effective programs that have been proven on the basis of rigorous scientific research to change behavior, which means delaying sexual activity, increasing condom or contraceptive use for sexually active youth, or reducing pregnancy among youth. They also are required to be medically accurate and age-appropriate. As mentioned earlier, HHS established, through a systematic review, a list of 31 program models that are considered evidence-based programs that have been found to be effective in achieving one of the behavioral outcomes: delaying sexual activity, increasing condom or contraception use for sexually active youth, or reducing pregnancy among youth. These evidence-based models are examples of programs that are eligible for replication and the programs from which states can incorporate significant elements. States are required to assure that their program (1) addresses both abstinence and contraception, and (2) incorporates at least three of the adult preparation subjects. Tribal PREP (funded at $3.250 million annually) provides grants to tribes and tribal organizations to implement PREP. It supports 16 grantees and projects. Programs are encouraged to use models 60 For a list of the grantees, see http://www.acf.hhs.gov/programs/fysb/resource/2014-state-prep-awards. Florida, Indiana, North Dakota, Texas, and Virginia and the territories of American Samoa, Guam, the Marshall Islands, the Northern Mariana Islands, and Palau chose not to take state PREP funding (FY2014 data). 62 If the state government opted not to apply after two years, the funding allotted to that state became available on a competitive basis to other organizations in the state. For the five states and three territories that opted not to take the PREP funding in FY2010 and FY2011, 37 Competitive Personal Responsibility Education Program grants totaling approximately $19 million were awarded for FY2012 to entities in those states and territories on a competitive basis. (These are three year grants, with the funding level listed being the FY2012 amount. FY2013 amounts were subject to sequestration. For a list of the grantees, see https://www.acf.hhs.gov/programs/fysb/resource/2012-cprep-awards). 61 Congressional Research Service 15 Teenage Pregnancy Prevention: Statistics and Programs (or elements of models) of existing teen pregnancy prevention programs that have been proven by scientific research to be effective in changing behavior. Of the funding not awarded to states/territories, the HHS Secretary is required to annually reserve $10 million for competitive discretionary PREIS grants to organizations/entities to implement innovative youth pregnancy prevention strategies and target services to high-risk, vulnerable, and culturally under-represented youth populations, including youth in, and aging out of, foster care; homeless youth; youth with HIV/AIDS; pregnant and parenting women who are under 21 years of age and their partners; and youth residing in areas with high birth rates for youth.63 An entity that is awarded a PREIS grant is required to conduct a rigorous evaluation of their program and/or to agree, if selected, to participate in a rigorous federal evaluation of the activities funded by the grant. In addition, the HHS Secretary is required to reserve $6.5 million annually for expenditures by the Secretary to (1) provide (directly or through a competitive grant process) research, training, and technical assistance for the programs and activities funded by PREP allotments or grants; and (2) evaluate the program and activities funded by PREP allotments or grants.64 Title V Abstinence Education The Title V Abstinence Education Block Grant to states was authorized under P.L. 104-193 (the 1996 welfare reform law). The law provided $50 million per year for five years (FY1998FY2002) in federal funds specifically for the abstinence education program. Subsequently, the block grant was funded through June 30, 2009, by various legislative extensions. The Title V Abstinence Education program is considered a mandatory program and is funded by mandatory spending. It is a formula grant program. State funding is based on the proportion of low-income children in the state compared to the national total. Funds must be requested by states when they solicit Title V Maternal and Child Health (MCH) block grant funds. To ensure that the abstinence-only message is not diluted, the law (P.L. 104-193, §510 of the Social Security Act) stipulated that the term “abstinence education” means an educational or motivational program that (1) has as its exclusive purpose, teaching the social, psychological, and health gains of abstaining from sexual activity; (2) teaches abstinence from sexual activity outside of marriage as the expected standard for all school-age children; (3) teaches that abstinence is the only certain way to avoid out-of-wedlock pregnancy, STDs, and associated health problems; (4) teaches that a mutually faithful monogamous relationship within marriage is the expected standard of human sexual activity; (5) teaches that sexual activity outside of marriage is likely to have harmful psychological and physical effects; (6) teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society; (7) teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and (8) teaches the importance of attaining self-sufficiency before engaging in sex. 63 For a list of the grantees, see http://www.acf.hhs.gov/programs/fysb/resource/preis-summaries. For additional information on PREP, see Personal Responsibility Education Program (PREP) Evaluation, OPRE Report #2014-27, FYSB Report #2014-1, How States are Implementing Evidence-Based Teen Pregnancy Prevention Programs Through the Personal Responsibility Education Program, by Susan Zief, Rachel Shapiro, and Debra Strong (Mathematica Policy Research), April 2014 http://www.acf.hhs.gov/sites/default/files/opre/ prep_dis_brief_032814_edited.pdf. 64 Congressional Research Service 16 Teenage Pregnancy Prevention: Statistics and Programs The Title V Abstinence Education program must be used exclusively for teaching abstinence and may not be utilized in conjunction with, or for any other purpose. Title V Abstinence Education programs must be medically accurate. To receive federal funds, a state must match every $4 in federal funds with $3 in state funds.65 This means that full funding (from states and the federal government) for abstinence education must total at least $87.5 million annually. In FY2009, 27 states and Puerto Rico chose to sponsor a Title V Abstinence Education program. The program’s funding expired on June 30, 2009,66 but P.L. 111-148, the Patient Protection and Affordable Care Act (ACA), reauthorized the program and restored funding to the Title V Abstinence Education formula block grant to states at the previous annual level of $50 million for each of the years FY2010 through FY2014 ($250 million over five years).67 P.L. 113-93 (the Protecting Access to Medicare Act of 2014) which was enacted on April 1, 2014, extended the Title V Abstinence Education block grant ($50 million per year) through FY2015 (i.e., September 30, 2015). In FY2013, 36 states and 3 territories (Guam, Puerto Rico, and the Federated States of Micronesia) chose to sponsor a Title V Abstinence Education program.68 Adolescent Family Life Program The Adolescent Family Life (AFL) program was enacted as Title XX of the Public Health Service Act (P.L. 97-35) in 1981. It is administered by the Office of Adolescent Pregnancy programs in the Department of Health and Human Services (HHS). The AFL program has two basic components, the “care” component and the “prevention” component. AFL care demonstration projects are required to provide comprehensive health, education, and social services (including life and career planning, job training, safe housing, decision-making and social skills), either directly or through partnerships with other community agencies, and to evaluate new approaches for implementing these services. AFL care projects are based within a variety of settings such as universities, hospitals, schools, public health departments, or community agencies. Many provide home visiting services and all have partnerships with diverse community agencies. The AFL program supports care demonstration projects to develop, test, and evaluate interventions with pregnant and parenting teens, their infants, male partners, and family members in an effort to ameliorate the effects of too-early childbearing for teen parents, their babies, and their families. Care services to parenting adolescents include pre- and post-natal care, nutrition counseling, continuing education, and vocational services. 65 States use a variety of methods to meet the federal matching requirement, such as state funds, private or foundation funds, matching funds from community-based grantees, and in-kind services (e.g., volunteer staffing and public service announcements). 66 As mentioned above, since its inception, the Title V Abstinence Education Block Grant has been funded at a rate of $50 million per year. Funding for the program expired on June 30, 2009. Therefore, federal funding for the program for FY2009 was $37.5 million (i.e., a rate of $50 million per year for three-quarters of the fiscal year). 67 The Title V Abstinence Education block grant also was subject to sequestration. The FY2013 post-sequester operating level for the Title V Abstinence Education block grant was $47.5 million in FY2013. The FY2014 postsequester operating level for the Title V Abstinence Education block grant is $46.4 million in FY2014. 68 U.S. Department of Health and Human Services, Justification of Estimates for Appropriations Committees, HHS, Administration for Children and Families, FY2015, pp. 351-352. For information on the grantees, see http://www.acf.hhs.gov/programs/fysb/resource/2014-state-aegp-awards. Congressional Research Service 17 Teenage Pregnancy Prevention: Statistics and Programs From 1998 to 2009, the AFL appropriation was expended primarily on the prevention component of the AFL program (i.e., services for pre-teens, teens, and their families to promote abstinence from premarital sexual relations) to develop, test, and evaluate pregnancy prevention interventions designed to encourage adolescents to postpone sexual activity and reduce their risks for teenage pregnancy and sexually transmitted diseases. AFL prevention demonstration projects were required to develop, test, and use curricula that provide education and activities designed to encourage adolescents to postpone sexual activity until marriage. Since 1998, the prevention component of the AFL demonstration program was used to exclusively fund abstinence-only education projects that conformed to the definition of abstinence education defined in the Title V Abstinence Education Block Grant to states. Most of the AFL prevention projects tried to reach students between the ages of 9 and 14 in public schools, community settings, or family households; all involved significant interaction with parents to strengthen the abstinence message. Any public or private nonprofit organization or agency was eligible to apply for an AFL demonstration grant. AFL projects could be funded for up to five years; all grantees were required to reapply each year of their continuing grant. Every program that received AFL grant funds was required to include an independent evaluation component. The prevention component of the AFL demonstration program was funded at $9.0 million in FY1998 and FY1999; $9.1 million in FY2000 and FY2001; $10.2 million in each of the fiscal years FY2002 through FY2004; and $13.1 million in each of the fiscal years FY2005 through FY2009. No funding has been provided for the prevention component of the AFL program since FY2009.69 The FY2010 appropriation for the care component of the AFL program was $16.7 million. P.L. 111-117 stipulated that none of the AFL funds were to be used for “prevention” services or projects. Similarly, the FY2011 appropriation for the AFL program (P.L. 112-10) specified that the AFL funding was not to be used for AFL prevention services or projects. P.L. 112-10 included funding of $12.4 million for the AFL program for FY2011.70 No funding has been provided for the program since FY2011.71 Community-Based Abstinence Education (CBAE) Program Abstinence-only education funding (discretionary funding) provided through the CommunityBased Abstinence Education (CBAE) program was included in annual appropriations legislation, from FY2001 through FY2009. Note that the CBAE program was known as the Special Projects for Regional and National Significance (SPRANS) until FY2005. The CBAE program was 69 According to HHS, in 2010-2011 the AFL program was supporting 27 care demonstration projects across the country. AFL care projects are programs primarily for pregnant or parenting adolescents. 70 Note that the $12.4 million figure accounts for the 0.2% across-the-board rescission that was also included in P.L. 112-10. 71 The Obama Administration’s budget request for FY2012 did not include funding for the AFL program for FY2012. FY2012 budget document commentary stated: “Mandatory funding for the Pregnancy Assistance Fund was included in the Patient Protection and Affordable Care Act. This new program directs resources to similar populations and activities-making the AFL program duplicative. Therefore HHS has not provided funding to continue the AFL program”; http://www.hhs.gov/about/FY2012budget/gdm_cj_fy2012.pdf, p. 123. Congressional Research Service 18 Teenage Pregnancy Prevention: Statistics and Programs funded through Section 1110 of the Social Security Act for discretionary grants. P.L. 106-246 appropriated $20 million for abstinence education to HHS under the SPRANS program for FY2001 to bolster the abstinence-only message for adolescents ages 12 to 18. CBAE program competitive grants provided support to public and private entities for the development and implementation of abstinence-only education programs (that conform to the definition of abstinence education defined in the Title V Abstinence Education Block Grant to states) for adolescents ages 12 through 18 in communities nationwide. Funding for the CBAE program increased incrementally, from $20 million in FY2001 to $108.9 million in FY2008; in FY2009 CBAE funding dropped to $94.7 million. No CBAE funding has been appropriated since FY2009. Competitive Abstinence-Only Grants Several appropriation laws included an additional $5 million for competitive grants for abstinence-only education for each of FY2012, FY2013, FY2014, and FY2015. The most recent laws, P.L. 113-235/P.L. 113-164, included funding of $5 million for competitive grants for abstinence-only education for FY2015.72 P.L. 113-76, the Consolidated Appropriations Act, 2014 (enacted January 17, 2014), included funding of $5 million for competitive grants for abstinence-only education for FY2014.73 P.L. 113-6, the Consolidated and Further Continuing Appropriations Act, 2013 (enacted March 26, 2013), included pre-sequester funding of $5 million for competitive grants for abstinence-only education for FY2013. The post-sequester amount of funding for the competitive grants for abstinence-only education was $4.7 million in FY2013. P.L. 112-74, the Consolidated Appropriations Act, 2012 (enacted December 23, 2011), included funding of $5 million for competitive grants for abstinence-only education for FY2012. Other Federal Programs Although there are several federally funded programs that have a pregnancy prevention component and thereby may use their funds to provide pregnancy prevention information and/or contraception services to teenagers, they are not mandated by federal law to use any of their funds for teenagers. These programs include Medicaid Family Planning (Title XIX of the Social Security Act), Title X Family Planning, the Maternal and Child Health block grant (Title V of the Social Security Act), the Temporary Assistance for Needy Families (TANF) block grant (Title IVA of the Social Security Act), the Title XX Social Services block grant, and several other HHS programs. As implied above, the services provided by these programs are primarily targeted to adult women rather than teenagers, and the programs themselves make no attempt to isolate program expenditures for information and/or contraception services provided to teens.74 72 P.L. 113-164, the Continuing Appropriations Resolution, 2015 (enacted September 19, 2014) funded the competitive abstinence-only grants for FY2015 at the FY2014 rate of $5 million through December 11, 2014, or enactment of applicable appropriations legislation. Pursuant to P.L. 113-235, the Consolidated and Further Continuing Appropriations Act, 2015 (enacted December 16, 2014), the competitive abstinence-only grants are funded at $5 million for FY2015. 73 For information on the grantees, see http://www.acf.hhs.gov/programs/fysb/resource/2013-caegp-awards. 74 U.S. General Accounting Office, “Teen Pregnancy: State and Federal Efforts to Implement Prevention Programs and Measure Their Effectiveness,” GAO/HEHS-99-4, November 1998. (GAO is now known as the Government (continued...) Congressional Research Service 19 Teenage Pregnancy Prevention: Statistics and Programs As part of President Obama’s Teen Pregnancy Prevention Initiative (TPPI), the Center for Disease Control and Prevention (CDC) is partnering with the federal Office of the Assistant Secretary for Health (OASH) “to reduce teenage pregnancy and address disparities in teen pregnancy and birth rates. The OASH Office of Adolescent Health (OAH) is supporting public and private entities to fund medically accurate and age appropriate evidence-based or innovative program models to reduce teen pregnancy. The purpose of the program is to demonstrate the effectiveness of innovative, multicomponent, communitywide initiatives in reducing rates of teen pregnancy and births in communities with the highest rates, with a focus on reaching African American and Latino/Hispanic youth aged 15–19 years.”75 In addition, the mission of the CDC’s Division of Adolescent and School Health (DASH) is to prevent the most serious health risks among children, adolescents, and young adults. Such health risks include preventing unintended pregnancies among children, teens, and young adults. Evaluation of Teen Pregnancy Prevention Programs There is a growing body of literature on effective interventions for reducing teen pregnancy. These evidence-based programs have demonstrated impacts on sexual activity (including delaying initiation of sexual activity), contraceptive use, STDs/STIs, and pregnancy or births. Many analysts and researchers agree that effective teen pregnancy prevention programs (1) convince teens that not having sex or that using contraception consistently and carefully is the right thing to do; (2) last a sufficient length of time (i.e., more than a few weeks); (3) are operated by leaders who believe in their programs and who are adequately trained; (4) actively engage participants and personalize the program information; (5) address peer pressure issues; (6) teach communication skills; and (7) reflect the age, sexual experience, and culture of young persons in the programs.76 Others indicate that effective teen pregnancy prevention programs are often developed in cooperation with teens and experts, help clarify the teen’s values and develop the coping skills of teens, provide medically accurate information, have clear goals, focus on specific health behaviors, address psychological risk and protective factors, use trained educators, and provide ongoing support.77 The Office of Adolescent Health (OAH), established within HHS in FY2010, coordinates adolescent health programs and initiatives across HHS related to adolescent health promotion and disease prevention. The OAH supports multi-disciplinary projects focused on improving adolescent health, collects and disseminates information on adolescent health to health professionals and the general public, and works in partnership with other HHS agencies to support evidence-based approaches to improving the health of adolescents. OAH provides a list of 31 programs/initiatives/interventions that it deems to be effective and suitable for replication.78 (...continued) Accountability Office.) 75 For more information, see the following webpage: http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/about/ communitywide.html. 76 Katy Suellentrop, What Works 2011-2012: Curriculum-Based Programs That Help Prevent Teen Pregnancy, The National Campaign to Prevent Teen Pregnancy, p. 5. 77 Kristen Anderson Moore (Child Trends), What If We took Research Seriously: What Would Teen Pregnancy Programs Look Like?, Presentation to the Healthy Teen Network, October 27, 2010. 78 The list of the 31 programs can be found at http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/db/ (continued...) Congressional Research Service 20 Teenage Pregnancy Prevention: Statistics and Programs The list of 31 evidence-based models showcases a wide range of programs, including those that are curriculum-based (aimed at educating teens on responsible behaviors) and those that are clinic-based (aimed at teens seeking contraceptive services), in several types of settings (e.g., schools, community centers). The evidence-based programs vary in the types of program models used and the populations targeted (e.g., African American youth, Hispanic youth, persons in the juvenile justice system). They include programs that focus on abstinence as a way to prevent teen pregnancy and sexually transmitted infections and programs that focus on improving contraceptive use among sexually active teens.79 The evidence-based approach to teen pregnancy prevention is based on the principle that services or programs that work (i.e., are proven to be effective) should be replicated or expanded upon by entities seeking federal dollars to prevent pregnancy among young people. The list of 31 includes three abstinence-only education programs.80 Prior to those three programs, which were found to be effective, it was widely held that the abstinence-only approach was ineffective.81 Moreover, another study of the abstinence-only strategy, not counted in the 31, also found positive results. The scientifically based study assigned African American students in the 6th and 7th grades to (1) an 8-hour abstinence-only intervention to reduce sexual intercourse; (2) an 8-hour safer sex intervention to increase condom use; (3) 8-hour and 12-hour comprehensive interventions to reduce sexual intercourse and/or increase condom use; or (4) a control group wherein an 8-hour health promotion intervention was used to improve healthy behaviors unrelated to sexual behavior (i.e., informed students about behaviors associated with heart disease, hypertension, stroke, diabetes, and certain cancers). The study found that only about 34% of the student participants in the abstinence-only intervention said that they had engaged in sexual intercourse,82 whereas about 49% of the students in the control group reported (during the twoyear follow-up interview) that they had engaged in sexual intercourse.83 The authors also reported that among the participants in the abstinence-only intervention who had engaged in sexual (...continued) programs.html. 79 The National Campaign to Prevent Teen and Unplanned Pregnancy, Types of Programs Funded Through the Office of Adolescent Health Funding Announcement, April 2010. 80 The following are considered abstinence-only education programs: (1) Heritage Keepers Abstinence Education; (2) Making a Difference!; and (3) Promoting Health Among Teens! Abstinence Only Intervention. 81 This viewpoint was in large part based on the 2007 Mathematica Policy Research, Inc., report that presented the final results from a multi-year, experimentally based impact study on several abstinence-only block grant programs. The report focused on four selected Title V abstinence education programs for elementary and middle school students. Based on follow-up data collected from youth (ages 10 to 14) four to six years after study enrollment, the report, among other things, presented the estimated program impacts on sexual abstinence and risks of pregnancy and STDs. The report found that program participants had just as many sexual partners as non-participants, had sex at the same median age as non-participants, and were just as likely to use contraception as non-participants; Christopher Trenholm, Barbara Devaney, Ken Fortson, Lisa Quay, Justin Wheeler, and Melissa Clark, “Impacts of Four Title V, Section 510 Abstinence Education Programs (final report),” Mathematica Policy Research, Inc., April 2007, http://aspe.hhs.gov/ hsp/abstinence07/. 82 The participants were interviewed two years after the intervention. 83 John B Jemmott III, Loretta S. Jemmott, and Geoffrey T. Fong, “Efficacy of a Theory-Based Abstinence-Only Intervention Over 24 Months,” Archives of Pediatrics and Adolescent Medicine, v. 164, no. 2, February 2010, pp. 152159. (Note: The authors remarked that the abstinence-only intervention studied would not meet the federal criteria for an abstinence-only program. One difference between the abstinence-only intervention studied and the Title V Abstinence Education block grant program was that the target behavior of the intervention was to abstain from any form of sexual intercourse (vaginal, anal, or oral) until a time later in life when the adolescent is more prepared to handle the consequences of sex, whereas one of the necessary components of the federal abstinence-only education programs was to teach school-age children that they were expected to abstain from sexual activity until they got married.) Congressional Research Service 21 Teenage Pregnancy Prevention: Statistics and Programs activity during the demonstration, there was no significant difference between the abstinence-only intervention participants and the control group participants regarding consistent condom use.84 The authors further noted that none of the interventions had significant effects on consistent condom use.85 The teen pregnancy prevention arena has grown substantially with respect to program evaluation. There is a growing evidence base of activities and services that have been shown to be effective in reducing teen pregnancy, delaying sexual activity among young people, and reducing sexually transmitted infections. Moreover, the number of evaluations/studies that have used a scientific approach with experimental and control groups (an approach that most analysts agree provides more reliable, valid, and objective information than other types of evaluations) have also increased.86 A recent report states: The movement to shift public and philanthropic funding to support “what works” has made real gains in the last few years. Government and philanthropy are seeking to identify highimpact programs that have been tested in rigorous trials and found to deliver superior results for society. However, it is not enough to identify what works—we also have to identify how it works so that other organizations can replicate the implementation of the program and get similar results.87 The teen pregnancy prevention programs (i.e., Tier 1 TPP and state formula and competitive PREP) are federally mandated to replicate evidence-based programs. Tier 2 TPP and PREIS are mandated to implement innovative strategies to prevent teen pregnancy and STIs. Both the TPP program and PREP provide funding for evaluation. Replication of programs and evaluation of new programs will add to the evidence base regarding what works and what does not work with regard to teen pregnancy prevention.88 OAH supports several evaluation activities to continue to build the evidence base for what works to prevent teenage pregnancy. OAH currently provides funding to 35 Teen Pregnancy Prevention (TPP) grantees to conduct an independent, rigorous evaluation of their programs; 16 grantees are evaluating their efforts to replicate evidence-based programs and 19 grantees are evaluating new and innovative teen pregnancy prevention programs. In addition, OAH funds two large multi-site federal evaluations focused on teen pregnancy prevention.89 Upon authorizing the PREP program, Congress required that it be evaluated. The evaluation will help the federal government, states, tribes and tribal communities, and local service providers learn more about program design, implementation, and outcomes. The Administration for 84 According to the study, 76% of the abstinence-only participants who had engaged in sexual activity had used condoms consistently during intercourse in the past three months, whereas 78% of the control group participants had used condoms consistently. 85 John B Jemmott III, Loretta S. Jemmott, and Geoffrey T. Fong, “Efficacy of a Theory-Based Abstinence-Only Intervention Over 24 Months,” Archives of Pediatrics and Adolescent Medicine, v. 164, no. 2, February 2010, p. 157. 86 Ron Haskins and Greg Margolis, Show Me the Evidence: Obama’s Fight for Rigor and Results in Social Policy, Brookings Institution Press, Washington, DC, 2014. 87 The Bridgespan Group, What Does It Take to Implement Evidence-Based Practices? A Teen Pregnancy Prevention Program Shows the Way, by Daniel Stid, Alex Neuhoff, Laura Burkhauser, and Bradley Seeman, November 11, 2013, p. 2. 88 U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation, Evidence-Based Initiatives: Opportunities and Challenges, by Barbara Broman (Associate Deputy Assistant Secretary for Human Services Policy). 89 See the following webpage: http://www.hhs.gov/ash/oah/oah-initiatives/for-grantees/evaluation/. Congressional Research Service 22 Teenage Pregnancy Prevention: Statistics and Programs Children and Families (ACF) within HHS contracted with Mathematica Policy Research (and its subcontractors—Child Trends, Twin Peaks Partners, Decision Information Resources, Public Strategies, and Chapin Hall) to document and assess this large-scale replication effort. The evaluation will study PREP programs nationwide, collecting data from all grantees, and will also conduct an in-depth examination of a few selected PREP sites.90 90 See the following webpage: http://www.prepeval.com/. Also see Personal Responsibility Education Program (PREP) Evaluation, OPRE Report #2014-27, FYSB Report #2014-1, How States are Implementing Evidence-Based Teen Pregnancy Prevention Programs Through the Personal Responsibility Education Program, by Susan Zief, Rachel Shapiro, and Debra Strong (Mathematica Policy Research), April 2014. Note: The first product of the PREP multicomponent evaluation, led by Mathematica Policy Research, was published in October 2013 and is entitled “PREP: Launching a Nationwide Adolescent Pregnancy Prevention Effort” (OPRE Report 2013-37). Congressional Research Service 23 Appendix. Federal Teen Pregnancy Prevention Program Funding: FY1998-FY2015 Table A-1. Federal Teen Pregnancy Prevention Program Funding, FY1998-FY2015 (millions of dollars) Teen Pregnancy Prevention (TPP) Program Evaluation Funds for TPP Program Personal Responsibility Title V Education Abstinence Program Education (PREP) Block Grant CommunityBased Abstinence Education (CBAE) Program Evaluation Funds for CBAE Program Competitive AbstinenceOnly Grants Adolescent Family Life (AFL) Program— “Care” Component Adolescent Family Life (AFL) Program— “Prevention” Component FY1998 — — — $50.0 — — — $7.7 $9.0 FY1999 — — — 50.0 — — — 8.7 9.0 FY2000 — — — 50.0 — — — 10.2 9.1 FY2001 — — — 50.0 $20.0 — — 15.3 9.1 FY2002 — — — 50.0 40.0 — — 18.7 10.2 FY2003 — — — 50.0 54.6 — — 20.7 10.2 FY2004 — — — 50.0 70.0 $4.5 — 20.5 10.2 FY2005 — — — 50.0 99.2 4.5 — 17.6 13.1 FY2006 — — — 50.0 108.8 4.5 — 17.6 13.1 FY2007 — — — 50.0 108.9 4.5 — 17.6 13.1 FY2008 — — — 50.0 108.9 4.5 — 16.7 13.1 FY2009 — — — 37.5 94.7 4.5 — 16.7 13.1 FY2010 $110.0 $4.5 $75.0 50.0 0.0 0.0 — 16.7 0.0 FY2011 104.8 4.4 75.0 50.0 0.0 0.0 — 12.4 0.0 CRS-24 FY2012 104.8 8.5 75.0 50.0 0.0 0.0 $5.0 0.0 0.0 FY2013 98.4 8.5 71.2 47.5 0.0 0.0 4.7 0.0 0.0 FY2014 101.0 8.5 69.6 46.4 0.0 0.0 5.0 0.0 0.0 FY2015 101.0 6.8 75.0 50.0 0.0 0.0 5.0 0.0 0.0 $620.0 $41.2 $440.8 $881.4 $705.1 $27.0 $19.7 $217.1 $132.3 Total Source: Table prepared by the Congressional Research Service based on data from the Department of Health and Human Services (HHS). Notes: These data reflect appropriations after all rescissions and post-sequester for FY2013 and FY2014. Dashes indicate that program was not yet authorized. CRS-25 Teenage Pregnancy Prevention: Statistics and Programs Author Contact Information Carmen Solomon-Fears Specialist in Social Policy csolomonfears@crs.loc.gov, 7-7306 Congressional Research Service 26