To be rather than not to be--that is the problem with the questions we ask adolescents about their childbearing intentions

OBJECTIVE

To demonstrate that rephrasing the questions used to assess childbearing intentions to quantify the strength of the intent to remain nonpregnant, rather than the strength of the intent to become pregnant, would make teenagers' responses more useful to health care providers, family planning counselors, and health policy makers.

METHODS

Examples from the teen pregnancy prevention literature are used to support the recommendations for change.

RESULTS

Teenagers rarely plan their pregnancies. However, because those who are having sexual intercourse must actively try not to become pregnant or they will likely conceive, teenagers often become pregnant because they lack a firm commitment not to do so. Thus, to accurately profile the antecedents of adolescent pregnancy, (1) the questions used to assess childbearing intentions must be rephrased so that teenagers who intend to remain nonpregnant can be distinguished from those who do not and (2) separate differential diagnoses must be developed for inconsistent contraceptive use within these 2 groups of teenagers who are at risk for unintended pregnancy.

CONCLUSION

Asking sexually active teenagers about the strength of their intent to remain nonpregnant will make the results of office interviews and national surveys more useful because the responses such questions elicit will enable health care providers and policy makers to target common, modifiable antecedents of inconsistent contraceptive use for interventions.

A randomized trial of augmented prenatal care for multiple-risk, Medicaid-eligible African American women

OBJECTIVES

This project investigated whether augmented prenatal care for high-risk African American women would improve pregnancy outcomes and patients' knowledge of risks, satisfaction with care, and behavior.

METHODS

The women enrolled were African American, were eligible for Medicaid, had scored 10 or higher on a risk assessment scale, were 16 years or older, and had no major medical complications. They were randomly assigned to augmented care (n = 318) or usual care (n = 301). Augmented care included educationally oriented peer groups, additional appointments, extended time with clinicians, and other supports.

RESULTS

Women in augmented care rated their care as more helpful, knew more about their risk conditions, and spent more time with their nurse-providers than did women in usual care. More smokers in augmented care quit smoking. Pregnancy outcomes did not differ significantly between the groups; however, among patients in augmented care, rates of preterm births were lower and cesarean deliveries and stays in neonatal intensive care units occurred in smaller proportions. Both groups had lower-than-predicted rates of low birthweight.

CONCLUSIONS

High-quality prenatal care, emphasizing education, health promotion, and social support, significantly increased women's satisfaction, knowledge of risk conditions, and perceived mastery in their lives, but it did not reduce low birthweight.

Smoking reduction activities in a federal program to reduce infant mortality among high risk women

OBJECTIVES

To determine the smoking cessation/reduction services offered to pregnant women by federally funded Healthy Start projects designed to reduce infant mortality.

DESIGN

Information was obtained by questionnaires sent to all Healthy Start projects in 1999. Responses were received from 76 sites.

SETTING

The federal government selected the Healthy Start sites on the basis of infant mortality rates that were much in excess of the national average.

PATIENTS

The projects served largely minority clients. Most of the women were poor and eligible for Medicaid.

MAIN OUTCOME MEASURES

The services that projects offered to pregnant smokers, the priority given the smoking related activities, and whether more should be done.

RESULTS

Only 23% of the sites thought that they were doing enough to help pregnant smokers stop or reduce smoking. The sites felt the national office should develop a manual of best practices, provide client materials, and organise workshops. While three quarters of the sites expected home visitors to counsel pregnant smokers, less than half provided training in this area during orientation, but most visitors received on-the-job training. Only 64% of sites gave smoking cessation/reduction activities high priority in comparison to other objectives of home visiting.

CONCLUSIONS

Although Healthy Start sites were aware of the importance of smoking cessation/reduction activities for their clients, they offered a limited range of services. These projects, and others with similar objectives serving similar populations, need a better understanding of the time and money such interventions require and greater belief in their effectiveness, along with more funds, staff training and materials, and office systems that promote counselling.

The intendedness of pregnancy: a concept in transition

BACKGROUND

Although interest in the intendedness or the planning status of a pregnancy goes back many centuries, it is only since 1941 that questions about these issues have been asked systematically in large-scale surveys. More recently, questions about intendedness have become standard features of the National Survey of Family Growth and of the Pregnancy Risk Assessment Monitoring System (PRAMS). Interest in and concern about the large numbers of unintended pregnancies reported in those surveys resulted in an Institute of Medicine report on the subject and the inclusion of a national health objective for increasing the proportion of pregnancies that are intended in Healthy People 2000 and Healthy People 2010.

NEEDS

The terms, "intended," "unintended," "mistimed," "wanted," "unwanted," and "planned" are often used without significant attention being paid to their meaning or how they are derived from survey questions. There is a particular need to distinguish between terms that define attitudes and those that define behaviors. In addition, research has revealed that women are often happy despite experiencing an unintended pregnancy and that contraceptive failures do not always result in a report of an unintended pregnancy.

OBJECTIVES

Researchers have begun to ask questions about the meaning of the intendedness concept and its relationship to what women express as their feelings about pregnancies and births. This article, and this entire issue, is an attempt to make the reader aware of the current issues in this area and to suggest additional research that is needed to enable policy makers and program planners to design programs that will better assist couples in meeting their fertility goals.

Infant mortality review as a vehicle for quality improvement in a local health department

BACKGROUND

Many communities across the United States have established fetal and infant mortality review (FIMR) programs as a way of gaining insight into the causes of such deaths and of devising and implementing ways to improve the health of pregnant women and their infants.

IMR PROCESS

The IMR process in the Jefferson County Department of Health in Birmingham, Alabama, evolved in a somewhat different fashion than that in other communities. A technical review team reviews all the infant deaths in the county, with particular attention to each woman's pregnancy history. A community review team reviews composite cases that illustrate some particular problem that might lead to infant mortality, such as teenage pregnancy or short intervals between pregnancies. This team provides insights into cultural patterns and a community perspective on the problems. Recommendations from the two teams are acted on by the health department, with the assistance of other agencies as needed.

IMPACT OF THE IMR PROCESS

The IMR process has been used to increase community agency participation in health department activities, improve health department procedures, increase health department staff acceptance of a new and controversial program (Healthy Start), and offer services to women who need them.

CONCLUSIONS

IMR has become a mechanism for CQI in the health department, embodying many of the principles of CQI, including the use of teams, focus on a team mission, and examination of processes, not individuals. The program offers a model of how to reduce rates of fetal and infant mortality.

Douching: a problem for adolescent girls and young women

OBJECTIVE

To compile available published data on the prevalence of douching practices in adolescent girls and young women and the effects of douching on gynecologic health, including studies of gynecologic changes due to douching in adolescent girls and young women, surveys that demonstrated the prevalence of douching in the populations, and policy statements or lack thereof from professional and medical organizations with regard to the practice of douching.

DATA SOURCES

We did Internet searches, including a MEDLINE search, a literature review, and used the telephone, mail, and e-mail to contact professional organizations.

RESULTS

Douching has been found to be strongly associated with increased risk for pelvic inflammatory disease, bacterial vaginosis, and ectopic pregnancy, the former of which is especially prevalent in adolescent girls and young women. Douching is practiced by 15.5% of adolescent girls and young women in the United States, with significantly higher prevalences in certain groups in the population. We have not found any official position of professional and medical organizations on the practice of douching.

CONCLUSIONS

Because vaginal douching has been shown to be associated with bacterial vaginosis, pelvic inflammatory disease, and ectopic pregnancy, and because no benefits are conferred on those who practice it, douching should be discouraged among adolescent girls and young women. There is a great need for further studies, particularly prospective ones, to determine if there is evidence of a direct causative influence of douching on pelvic inflammatory disease, ectopic pregnancy, and/or bacterial vaginosis, and to determine why adolescent girls and young women douche.

A simple, effective method that midwives can use to help pregnant women stop smoking

Recent studies suggest that few maternity care providers are offering the assistance that women need to reduce or stop smoking during pregnancy. This is probably because of a lack of conviction among providers that they can be effective, a perception that they lack counseling skills, and the absence of reimbursement for counseling and self-help materials. Midwives have strong counseling skills and materials will soon be available that can help them and others become trained smoking counselors. Thus, midwives can easily adopt the techniques that have been shown effective in reducing or stopping smoking during pregnancy. These are a 5- to 10-minute counseling session at the first prenatal visit by a trained provider plus appropriate print materials (pregnancy-specific and culturally- and reading-level-appropriate). Guiding the smoker to select a date for quitting and checking on smoking status at each visit increase the likelihood of behavior change. These techniques should increase the quit rate, over spontaneous quitting, by 10%-20%. Managed care organizations looking for ways to reduce costly hospitalizations for low birth weight infants or ambulatory care visits for smoking-related illnesses in infants and children should support this intervention. Medicaid and tobacco settlement funds are potential sources of reimbursement for counseling and educational materials.

How legislation and health systems can promote adolescent health

This chapter focuses on some of the laws and regulations that could make it easier for adolescents to adopt health-promoting and disease-preventing behaviors, or that have minimized the dangers that might be caused by their behaviors. It also reviews some of the aspects of health care systems that may present barriers to health-promoting behaviors and suggests how they might be changed.

A collaborative effort to develop a data collection system

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The impact of short interpregnancy intervals on pregnancy outcomes in a low-income population

OBJECTIVES

The objective of this study was to determine whether the length of the interval between pregnancies was associated with either preterm birth or intrauterine growth retardation in a low-income, largely Black population.

METHODS

The study population consisted of 4400 women who had received prenatal care in county clinics and had two consecutive singleton births between 1980 and 1990.

RESULTS

Interpregnancy intervals were positively associated with age and negatively associated with the trimester in which care was initiated in the second pregnancy. Whites had shorter intervals than non-Whites. The percentage of preterm births increased as the length of the interpregnancy interval decreased, but only for women who had not had a previous preterm birth. The association between interval and preterm birth was maintained when other factors associated with preterm birth were controlled. There was no significant relationship between intrauterine growth retardation and interpregnancy interval.

CONCLUSIONS

Women, particularly those who are poor and young, should be advised of the potential harm to their infants of short interpregnancy intervals.

Medical status of adolescents at time of admission to a juvenile detention center

PURPOSE

To examine the medical status and history of health care utilization of adolescents at the time of their admission to a juvenile detention facility.

METHODS

Data were collected over an 18-month period on all detainees admitted for the first time to a juvenile detention facility in a major southeastern city in the United States. Information was gathered through a private, confidential interview completed by a medical social worker and a physical examination by a physician. Information was obtained regarding past medical history, complaints at the time of admission, health care utilization, and physical examination.

RESULTS

Approximately 10% of teenagers admitted to a detention facility have a significant medical problem (excluding drug/alcohol abuse, or uncomplicated sexually transmitted diseases) that requires medical follow-up. The majority of these conditions were known to the adolescent at the time of admission. Only a third of adolescents admitted to the detention facility reported a regular source of medical care, and only about 20% reported having a private physician. A majority of all the detainees had already fallen behind in or dropped out of school. More than half of the families of the adolescents with a medical problem appeared to be unable or unwilling to assist in ensuring proper medical follow-up.

CONCLUSIONS

A significant percentage of adolescents entering a detention facility have a medical problem requiring health care services. Detention facilities offer an opportunity to deliver and coordinate medical care to high-risk adolescents. Programs linking public and private health care providers with the correctional care system may provide juveniles with an acceptable option for obtaining needed health care services.

Rural adolescent pregnancy: a view from the South

An analysis of 1990 census and vital statistics data for eight Southeastern states revealed that the teenage birthrate generally was higher in rural than in metropolitan areas; the exception was among black women aged 15-17. The highest birthrate was 162 births per 1,000 among rural black women aged 18-19. Abortion rates were much lower for rural teenagers than for urban teenagers, regardless of race. For 15-17-year-olds, white women had an abortion rate of 12 abortions per 1,000 in rural counties and 18 per 1,000 in metropolitan counties; black women had rates of 13 per 1,000 and 30 per 1,000 in rural and metropolitan areas, respectively. Similarly, the abortion ratio was lower in rural than in urban areas; for example, 18% of rural white women aged 18-19 who became pregnant had an abortion, compared with 35% of their metropolitan counterparts. Black 15-17-year-olds in metropolitan areas had a higher pregnancy rate (106 per 1,000) than those in rural counties (87 per 1,000). The pregnancy rate of white women aged 15-17 was similar in rural [corrected] and metropolitan areas (about 46 per 1,000). Among rural women aged 18-19, 32% of births to whites and 45% of those to blacks resulted from a second or higher order pregnancy.

After graduation, what? An analysis of the job placements of graduates of public health maternal and child health training programs. Project of the Association of Teachers of Maternal and Child Health

OBJECTIVES

In 1995, the Association of Teachers of Maternal and Child Health (ATMCH) decided that information about the employment status of program graduates was essential to attempts to improve MCH curricula.

METHOD

ATMCH requested information from 13 MCH programs in schools of public health funded by the federal Maternal and Child Health Bureau and 12 provided information about their master's degree graduates in the 1990-1994 period, including the year of graduation, degree, Bureau traineeship support, position held, and employing agency.

RESULTS

The total number of graduates was 742. Four programs averaged less than 8 graduates per year (small); six, 10-16 (midsize); and two more than 22 (large). More than 90% of graduates received a M.P.H. In the 10 programs that provided data on Bureau support, 46% received traineeship support from the Bureau. Midsize programs had the largest percentage of graduates receiving traineeship support. Overall, 45% of graduates were in administrative positions, 32% were involved in patient care, 20% were in policy-analytic positions, and 3% in other positions. Forty-seven percent of program graduates entered into or continued in community-based agencies, 18% in government agencies, 17% in academic or research agencies, and 18% in other agencies. Program size was significantly associated with both position and the agency in which the graduate was employed. Bureau traineeship support was associated with employing agency.

CONCLUSIONS

The study suggests the need for changes in MCH curricula, enhanced education opportunities in specialty skill areas, and an ongoing survey of graduates of MCH programs.

Promoting the well-being of children: the need to broaden our vision--the 1996 Martha May Eliot Award Lecture

As those in the field of maternal and child health attempt to redefine their role to meet the challenges of the 1990s and beyond, they should review the history of their field. They should examine the legacy of the Children's Bureau which investigated and reported upon all matters pertaining to the welfare of children. They should note the medicalization of MCH and the drift away from broader child welfare issues. In Dr. Eliot's words, they should remember "the inseparability of the health and social aspects of the growth and development of a child." MCHers can advance the well-being of children by defining child health broadly and by promoting it in many ways.

Procreative experiences and orientations toward paternity held by incarcerated adolescent males

PURPOSE

To describe the procreative experiences and the attitudes related to paternity held by a sample of incarcerated adolescent males.

METHODS

All adolescent males who were admitted to a long-term correctional facility between July 1994 and October 1994 were asked to participate in a confidential, face-to-face interview.

RESULTS

One hundred twenty-five incarcerated adolescents agreed to participate in the study. Over one-quarter (25.6%) of the respondents reported having ever gotten a girl pregnant; 40.6% of fathers reported having caused more than one pregnancy. A majority of respondents believed that fathering a child would be desirable, that they would be capable of being a father to a child, and that they could be responsible for the baby and mother. Fathers were more likely than nonfathers and black respondents were more likely than white respondents to report that they, their parents, and their friends would be pleased were they to get girls pregnant. Black respondents were more likely than white respondents to believe that they could be a good father to a child.

CONCLUSIONS

The general perceptions that fathering a child as a teenager is desirable and that they could be good fathers to their children will make the prevention of pregnancy and parenting difficult in this population. Incarcerated adolescents should be educated about parenting prevention using interventions that take into consideration their attitudes and perceptions of teenage parenting.

Medical, psychosocial, and behavioral risk factors do not explain the increased risk for low birth weight among black women

OBJECTIVE

Our purpose was to determine whether various demographic, behavioral, housing, psychosocial, or medical characteristics explain the difference in pregnancy outcome between black and white women.

STUDY DESIGN

A sample of 1491 multiparous women with singleton pregnancies, 69% of whom were black and 31% of whom were white and who enrolled for care between Oct. 1, 1985, and March 30, 1988, participated in the study. The frequencies of various demographic, medical environmental, and psychosocial risk factors among black and white women were determined. The outcome measures were birth weight, gestational age, fetal growth restriction, preterm delivery and low birth weight.

RESULTS

White infants were heavier and born later than black infants. The white women in this sample smoked more cigarettes, moved more frequently, and had worse psychosocial scores. The black women had lower incomes, were less likely to be married, and had more hypertension, anemia, and diabetes. Besides race, only maternal height, weight, blood pressure, diabetes, and smoking had a consistent impact on outcome and did not explain the difference in outcome between the two groups.

CONCLUSION

In this low-income population, many of the risk factors for low birth weight were more common among white women than black women. Nevertheless, black women had more infants born preterm, with growth restriction, and with low birth weight than did white women. The various maternal characteristics studied did not explain these differences.

Collaborative needs assessment and systems development in Alabama: Process and products

This article describes the implementation of a collaborative project and its results, involving a department of maternal and child health (DMCH) in a school of public health and a state department of public health. The state received a federal grant to enhance systems development for women and children. Adequate information regarding the existing system of health care was lacking. The state contracted with the DMCH for assistance in designing and conducting a needs assessment, whose purpose was to (1) identify strengths and weaknesses in the state system of care, (2) provide baseline information for targeting resources and measuring change, and (3) initiate an on-going process of assessment and evaluation of need. The DMCH collected data about financial and nonfinancial barriers to care from state-level health agency and organization experts, county-level service personnel, and consumers. The contributions to understanding the needs of the state offered by the information garnered in the three surveys helped the state in setting immediate and long-range objectives. The presence of the school of public health and the focus of its particular DMCH on assisting state agencies provided an atmosphere in which the state could ask for assistance and the university could respond in a way that was useful and relevant to the state's needs. Medical Subject Headings (MeSH): assessment, health planning, health priorities, interprofessional relations, program planning, public health.

Family planning: an essential component of prenatal care

This nation's traditional approach to improving maternal and infant health has been prenatal care. But evidence is mounting that additional progress in reducing maternal and infant morbidity and mortality will depend, at least in part, on the care that a woman receives before she conceives. The studies reviewed in this paper indicate that increasing the interval between deliveries and preventing or delaying pregnancies among women at high risk could lower the rate of low birthweight (LBW). Since reducing the rate of unintended pregnancies would also reduce the number of pregnancies in women at high risk of LBW because of race, age, late or no prenatal care, and unhealthy behaviors, the prevention of unintended pregnancies would also reduce LBW. Unfortunately, prenatal care, as experienced by many women, devotes little attention to these family planning issues. Many women do not realize the importance of family planning to their own health and that of their children. Prenatal care providers should include instruction about the importance of pregnancy planning and encourage women to continue receiving health care between pregnancies. If the health of women and infants is to be improved, society must be willing to provide health services to women of reproductive age even when they are not pregnant.

Perinatal health care policy: how it will affect the family in the 21st century

Demographic trends, pressures to reduce medical care costs and to improve access, biomedical research, and women's preferences for health care will result in many important changes in perinatal health care during the next 2 decades. These changes have the potential for influencing family structure and functioning. For example, the rates of teen-age pregnancy, unwanted or mistimed pregnancy, and infertility, with all their attendant adverse consequences, might be reduced.

Adolescent pregnancy and parenting: controversies of the past and lessons for the future

Recent research findings suggest that old ways of looking at adolescent sexuality, pregnancy, and parenting should be revised and that new approaches to service programs should be developed. This paper presents some new facts by examining the validity of nine beliefs about adolescent pregnancy: that nothing can reduce the rate of adolescent pregnancy; that pregnant adolescents experience poor pregnancy outcomes; that adolescent mothers do not complete their high school education; that pregnant adolescents have large families; that adolescent mothers remain on welfare for long periods; that pregnancy in adolescence is a mistake and, given a chance to overcome the immediate problems associated with it, young mothers can go on to lead normal lives; that welfare causes adolescent pregnancy and parenting; that adolescent mothers are poor parents; and that service programs can have a significant impact on adolescent pregnancy and parenting. Although programs aimed at the prevention and amelioration of the problems experienced by pregnant adolescents, young mothers, and their children and families have shown some success, relatively few are sufficiently powerful to bring about major changes--and even these are infrequently replicated because of high costs. Further progress in this area depends not only on new and expanded programs, but also on attacking the problem of poverty, which is an underlying cause of early sexual activity and childbearing.

Intergenerational transmission of school-age parenthood

A long-term follow-up of a group of black New Haven women who were young mothers in the late 1960s revealed that the majority of their offspring had not become parents by age 19. The offspring who experienced early parenthood were most likely to be female and to report significant depressive symptoms. Of those children--both male and female--who did become young parents, many were the offspring of women who had moved out of their mothers' homes within 26 months of the child's birth, and of women who reported suffering from lifetime depression. The data indicate that emotional deprivation, particularly at an early age, may predispose adolescents to seek emotional closeness through sexual activity and early parenthood.

School-age mothers: predictors of long-term educational and economic outcomes

The long-term effects of school-age pregnancy were investigated in a 20-year follow-up of a cohort of women who were pregnant adolescents in the late 1960s. Of the 149 living young black primiparas in the original cohort, 121 (81%) were located and interviewed. At follow-up the study population ranged in age from 32 to 38 years, 68% were unmarried, 71% had finished high school, 82% were completely self-supporting, and 27% reported living in public housing. Long-term success, defined as currently employed or supported by a spouse and a high school education (62%) or its equivalent, was associated with six features: having completed more school prior to becoming pregnant (odds ratio [OR] = 18; 95% confidence interval [CI] 2.3, 139.5); participating more actively in a program intervention offered to these pregnant teenagers 20 years ago (OR = 11.11; 95% CI 1.54, 79.87); being in school with no subsequent pregnancy at 26 months postpartum (OR = 10.1; 95% CI 1.64, 62.07); feeling in control of one's life (OR = 5.4; 95% CI 1.36, 21.54) and little social isolation (OR = 8.24; 95% CI 1.56, 43.50) at 26 months postpartum; and lifetime fertility control defined as one or two children after the index child (OR = 14.19; 95% CI 3.28, 61.29). It is concluded that most former teenage mothers complete a reasonable amount of education and are economically self-sufficient.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of source of prenatal care on care-seeking behavior and pregnancy outcomes among adolescents

This study measured the extent to which pregnancy outcomes of adolescents are related to the environment of the prenatal clinic where they receive care. The study sample consisted of women aged 18 years and under living in a medium-sized urban city in the Northeast, and who delivered their babies during 1984 or 1985 (N = 466). Hypotheses were tested using multiple regression analysis. Findings support the study's hypotheses: adolescents are likely to obtain more adequate care if the prenatal site is attractive and inviting, and if special efforts are made to register and retain them in care, and adequate care results in better outcomes.

School absence--a health perspective

Excessive school absence may result in difficulty in completing academic work, being retained in grade, or dropping out of school prior to high school graduation. Frequent or prolonged absence may be an indication that a student has a serious physical or emotional health problem, that he or she is engaged in problem behaviors with potentially serious health and social consequences, that other family members have physical or psychological problems, or that the student is reacting to an unfavorable school environment.

School-based clinics: their role in helping students meet the 1990 objectives

Service statistics and observations from site visits across the country indicate that school-based clinics (SBCs) may be having an impact on several of the problems targeted in the 1990 health objectives, including unplanned pregnancy and substance abuse. At least 120 junior and senior high schools in 61 communities are currently operating or developing clinics. Growth is attributed to increasing concern about high-risk youth, especially among educators in their roles of "surrogate parents"; to disillusion with categorical interventions and a movement toward more comprehensive services; and to student, parent, school, and community approval of the new programs. This article describes the comprehensive school-based clinic model, including its history, organizational strategies, school/community partnerships, and services.

Why adolescents do not attend school. The views of students and parents

Despite the magnitude and importance of the problem, little is known about why many students are absent from school. This study assessed what a sample of excessively absent students and their parents believed were the reasons for the students' absences. In response to an open-ended question about their main reason for absence, almost half of the students reported a health-related reason. When asked whether any of 15 potential problems contributed to their absence, many reported common and acute physical illnesses, headaches or stomachaches, and other aches or pains. Half mentioned factors relating to low motivation or a concern about the school environment. The parents' responses were remarkably similar except they were more likely to cite emotional problems of the student, school violence, and racial problems. When individual student's responses were compared with those of his or her parents, agreement on individual items were little better than would be expected by chance.

High-risk youth and health: the case of excessive school absence

Excessive school absence is a major educational and social problem in the United States, yet very little is known about its etiology or how to prevent or ameliorate it. This paper reports results from a series of related studies conducted in seven Boston middle schools (grades 6, 7, and 8) to test the hypotheses that health problems and unmet health needs are major characteristics distinguishing excessively absent students from regular attenders and that a health-oriented approach using medically mediated interventions is effective in reducing absences among excessively absent students. There were no significant differences between regular attenders and excessively absent students on multiple measures of student and family health status, health habits, and health service utilization patterns in a case-control study. The intervention program was not associated with a significant decrease in absence school-wide or for participating students. We conclude that demographic and educational characteristics of students exert a greater effect on their behavior in regard to absence from school than do health status or receipt of health services and that a health-oriented approach, such as the one used here, will not have a major impact on what remains one of the most profound educational and social problems involving children in the United States today.

Parental consent for abortion: impact of the Massachusetts law

This study assessed the impact of Massachusetts' parental consent law, which requires unmarried women under age 18 to obtain parental or judicial consent before having an abortion. Data were analyzed on monthly totals of abortions and births to Massachusetts minors prior to and following the April 1981 implementation of the law. Findings indicate that half as many minors obtained abortions in the state during the 20 months after the law went into effect as had done so previously. More than 1,800 minors residing in Massachusetts traveled to five surrounding states during these 20 months to avoid the statute's mandates. This group accounts for the reduction in in-state abortions. A small number of minors (50 to 100) bore children rather than aborting during 1982, perhaps because of the law. Findings suggest that this state's parental consent law had little effect on adolescent's pregnancy-resolution behavior.

School absence: a problem for the pediatrician

Children who are frequently or persistently absent from school tend to perform poorly in school and are likely to drop out before graduation from high school. Excessive school absence was significant implications in terms of maladaptive behavior, wasted opportunities, and future unemployment and welfare costs. Epidemiologic information about this problem suggests that physical and mental health problems of students or their families are the sole or contributing cause of this behavior in more than 50% of cases. Excessive school absence may signal such health problems as poor coping with or management of chronic illness, masked depression, teenage pregnancy, substance abuse, inappropriate responses to minor illnesses, or severe family dysfunction. School absence patterns appear to be a readily available, easy-to-use marker of childhood dysfunction which lends itself to screening large numbers of children for unmet health needs. Attention to this area of child behavior as part of routine health care will frequently uncover previously unrecognized health problems in children and their families.

Evaluating service delivery models for pregnant adolescents

Because programs for pregnant adolescents and teenage parents were developed locally, with little federal or state direction, no standard model of service delivery exists. Programs vary in degree of comprehensiveness and in primary location--hospital, school, social agency, or other. A common assumption, however, has been that multi-service programs providing health, educational, and social services have a greater impact on their participants than programs offering only one of these services. The study reported here tested this assumption by comparing the medical course and subsequent life histories of school-age mothers who participated in a comprehensive program during the prenatal period with those of young mothers who received only health-related services from a hospital in the same city. The relative impact of the two programs was examined controlling for social factors such as age, race, and socioeconomic status. With the exception of post-delivery educational status, the two study groups had similar medical and social outcomes. The educational difference, however, could not be attributed solely to the impact of the comprehensive program because of variations in educational status prior to entering the two programs. This study suggests that the comprehensive and hospital programs, with their unique emphases, served different groups of clients. The "goodness of fit" which existed between the program and clients demonstrates the need for multiple models of delivering services to school-age parents.

The use of socioeconomic data to predict teenage birth rates. An exploratory study in Massachusetts

In an exploratory study of adolescent fertility in 24 Massachusetts cities, age-specific birth rates constructed specifically for the study constituted the dependable variables. Data from the 1980 U.S. Census provided the independent socioeconomic variables for the analysis. The relationships between birth rates and these independent variables were explored through simple and partial correlation analyses. Results of the analyses confirm the assumption that rates of birth to teenagers vary systematically in relation to socioeconomic variables. They also confirm at the macro level the results of several earlier household survey showing an association between family income on the one hand, and adolescent sexual activity, contraception, and abortion on the other. In the current study, economic variables, particularly the median income of all families in the community, were found to be highly significant predictors of fertility among adolescents 15 to 19 years of age. The fertility of the generation to which the teenagers' mothers belonged (that is, women 35 to 44 years old) was also significantly associated with the teenagers' birth rates. The results for teenage mothers 15 through 17 years old and teenage mothers 18 and 19 years old were similar.

Changes in life style following mental hospitalization

The life situations of discharged mental hospital patients were examined by comparing living arrangements, employment, financial support, and role functioning before and after hospitalization for a sample of patients released from three state mental hospitals. Results indicate significant negative change for both males and females. These negative consequences seemed to be most often due to loss of employment and the accompanying decrease in financial support. Three possible explanations for the findings are discussed:a)effects of the hospitalization;b)effects of the psychiatric illness; or c) prior role socialization and competence.

Evaluating service programs for school-age parents: design problems

In response to increasing societal concern about school-age pregnancy, many communities have developed special medical, educational, and counseling service programs for pregnant girls and young parents. A small number of these programs have attempted to evaluate their accomplishments. Unfortunately, most of the reports suffer from methodological weaknesses. Such studies could be improved by use of properly selected control groups, improved analytic procedures, and specification of realistic program goals. To date, the range of evaluative methods has been narrow and most studies have been of largely minority populations. The reports indicate some success in the medical and short-range educational areas; but limited accomplishments in terms of long-term continuation of education, avoidance or delay of subsequent pregnancies, and achievement of economic independence. Suggestions are provided for improving both study design and program effectiveness.

Training psychiatrists in social research: problems and prospects

An integrated program of psychiatric residency training and doctoral studies in social welfare has been conducted by Brandeis University and two Worcester (Mass) clinical institutions over the last five years. Its goal has been to train psychiatrists to conduct psychiatric research using social science concepts and techniques. This article reviews the advantages of such a program, as well as its problems, in the context of current trends in psychiatric education and research. This program is also compared to others with similar goals that use different models of training.

Abortion, adoption, or motherhood: an empirical study of decision-making during pregnancy

Using matched samples (n = 249) of single, generally young black women, two thirds on welfare and previously pregnant, the study examined why some women decide to deliver while others, with almost identical sociodemographic and prior pregnancy experiences, decide to abort. Women delivering were in significantly longer relationships with partners who had also been less cooperative about contraception. Discussion with significant others occurred more often in decisions to deliver and greater support was received for that option. For many women the abortion decision and, to a lesser extent the decision to deliver, was conflictful, options evenly balanced, and considerable indecision reported. Attitudes about ethical aspects of abortion and knowledge of role models for single parenthood and seeking abortion among friends and relatives also discriminated the two samples. Women who delivered all previous pregnancies found the decision to abort particularly difficult. In this young population 29.2 per cent of women currently delivering had previously aborted; 55.8 per cent of women currently aborting had delivered. During their reproductive life, therefore, almost all women in this population will face the decision whether to abort and many will choose that option. Whether abortion or delivery is chosen will depend upon circumstances surrounding specific pregnancies rather than characteristics of the mother. Adoption is not an option in the pregnancy decision of women in this population.

Induced abortion and sterilization among women who became mothers as adolescents

Four cohorts of urban women who delivered a child before reaching age 18 were followed for periods ranging from 6 to 12 years to determine use of abortion and sterilization. The two more recent cohorts had been served by comprehensive service programs. About 40 per cent of each of teh groups used abortion or sterilization to control fertility. Most of the women seeking abortion had no subsequent term or near term deliveries, suggesting that such a request may signal a desire to terminate childbearing, at least for a few years. A high proportion of the young mothers obtained abortions during the second trimister, even for repeat abortion.