Reactions to Reviews of Recent Research
Lorraine V. Klerman, Dr.P.H.
Department of Maternal and Child Health
School of Public Health
University of Alabama at Birmingham
Prepared for program on Preventing Second Births to Teenage Mothers: Demonstration Findings, sponsored by the American Enterprise Institute for Public Policy Research on March 6, 1998, 1 to 4 pm, Washington, DC.
Preparation of this talk was made possible, in part, by a grant from the federal Maternal and Child Health Bureau (MCJ 9040).
The prevention of second and higher order births to very young women, unmarried women, and women who have not yet finished their high school education is of great interest to public health and particularly to those in maternal and child health. Research has shown that such births are associated with physical and mental health problems for the mother and the child, and often for other family members. Moreover, we in public health do not think that reliance on welfare is good for most families. Welfare provides too little money and is destructive of self-esteem. So we encourage attempts to reduce welfare rolls as long as such efforts do not lead to living conditions that imperil health, such as hunger, inadequate clothing or housing, or the inability to obtain medical care.
PUBLIC HEALTH PERSPECTIVE
What public health practitioners are most eager to see research undercover are ways to reduce first pregnancies among teenagers, especially those under age 19. But that is not the subject of today's meeting. Rather we are trying to understand why a teenager who has experienced the difficulties of raising a child, often under conditions of poverty and usually without a male partner, would allow herself to become pregnant again, often before the first child is two years old. Did they want to become pregnant again so soon? Most say "no." If they did not want to become pregnant again so quickly, why were they unable to prevent the pregnancies? The earlier speakers did not address these questions directly, although they will be addressed by the speaker who follows me. But an understanding of the underlying dynamics of teenage subsequent births is not essential to the development of programs to prevent them. Public health was able to prevent several diseases before there was a real understanding of the germ theory. What we in public health seek are programs that can be implemented in the communities across the United States that are experiencing high rates of adolescent pregnancy. These programs should be able to convince teenage mothers to delay a subsequent pregnancy until at least two years have past, they are over 20 years of age, they can support another child emotionally as well as financially, and, hopefully, they have married.
DIFFERENCES IN POPULATIONS
Both of the programs described earlier, the home visitation program in Elmira and Memphis and the Teenage Demonstration Program in Camden, Chicago, and Newark attempted to delay subsequent pregnancies--but they served somewhat different populations and used very different approaches.
A major difference between the two programs was the type of enrollment. Women were invited to join the home visitation program in Elmira and Memphis and most did; but it was not a requirement for any benefits that they were receiving. But enrollment was mandatory for all eligible women in the Teen Demo. If they did not enroll, they were sanctioned by the loss of a portion of their AFDC grant. Some enrolled only after threats and some only after being penalized, but most did eventually enroll.
There were other differences in the two populations. A larger percentage of the Teen Demo participants were under 20 years of age at enrollment (96%). The home visiting projein Elmira served largely Caucasian women and in Memphis largely African-Americans. While over three-quarters of the Teen Demo participants were African-American, there was a large Hispanic contingent (16%). The home visiting project only enrolled women who had no prior births, while many of the women in the Teen Demo already had one child (89%). The home visitors contacted their clients while they were pregnant (before the 30th week of pregnancy), while most of the Teen Demo participants were already taking care of infants and toddlers at enrollment. All the women in the Teen Demo were receiving AFDC payments at the time of enrollment, but not all the home visiting participants were.
DIFFERENCES IN PROGRAMS
But what is even more striking, and is the focus of our attention today, is the differences in the programs, especially as they might influence subsequent pregnancies. The home visiting program was considered a public health program, while the Teen Demo was considered a welfare program. Thus it is not surprising that participants' principal contact with the home visiting program was through a nurse, who had received extensive training (3 months) to prepare her for her role in this program. In the Teen Demo, the principal contact was a case manager, who also was specifically trained for this program, but less intensively. Few of the case managers had prior professional training, such as nursing or social work; many were paraprofessionals. Case loads in the Teen Demo program (50-60 clients) were double those in the home visiting program (20-25 families). The usual place of contact also differed. For the home visiting program, it was the home, with phone and other contacts being secondary. For the Teen Demo, contacts in the office of the case manager were the norm, although contacts at the home and in other offices did occur. The home visiting program stressed the involvement of others in planning for the mother and child. This included the male partner and the woman's family and friends. This was not a major element in the Teen Demo.
The focus of the two programs also differed. The home visiting program had more of a health focus, although improving the life course of the mother was also stressed. The Teen Demo was clearly a program whose objective was to make women self-sufficient and move them off the welfare roles. Good health, including family planning, was seen primarily as a way to accomplish this. The home visiting program's approach to its program objectives was through behavior modification, using various techniques including role modeling to change inappropriate behaviors. The Teen Demo stressed the transmission of information and used education as its major technique. Also, there were no financial incentives or disincentives in the home visiting program, while in the Teen Demo, those at the New Jersey sites would not receive additional money if they had another child because of the family cap provision in that state. And, at all sites, if women did not participate in the program, their AFDC grants could be reduced.
In terms of the family planning essential to the prevention of subsequent pregnancies, the programs again differed in emphasis and approach. Family planning received more emphasis in the home visiting program from the beginning and was always an important focus of the program. While in the Teen Demo, family planning was not initially a major focus, but received more attention as the case managers realized that pregnancies would impede their efforts to move their clients off the welfare rolls. In the home visiting program, the nurses' training program and their manual made it clear that family planning was one of many topics that nurses were expected to discuss with their clients and they were to discuss it in the context of planning for the woman's future and that of her child. Because of their professional training, the nurses were able to educate and counsel their clients about the various contraceptives. The family planning message came from the same individuals who offered messages about education, child care, and other issues. Again, possibly because of their clinical background, we suspect that the nurses were more directive and possibly more authoritative in their counseling. They probably emphasized that pregnancies should be delayed and that effective contraceptive use was the only way to do it. Their values and their advice were clear.
The situation in the Teen Demo was very different. Family planning was taught at one of three workshops, which was supposedly mandatory, but which was not always attended. The number of hours devoted to this subject varied among the sites (1.5 in Chicago and 54 in Newark), but the sites that devoted more hours to this subject found that their clients did not always complete the workshop! Only in Chicago did the case managers conduct the family planning workshop. In Camden, the health department had the responsibility and in Newark, the Planed Parenthood organization. Case managers at all sites were trained to provide family planning counseling, but the extent to which they did it undoubtedly varied. Moreover, anecdotal evidence suggests that some case managers gave a mixed message: don't have any more children but children are wonderful. Because of their lack of professional qualifications, the case managers may have been less explicit in their education and less directive in their counseling.
DIFFERENCES IN RESULTS
The results of the two programs were remarkably different. At the 46 month follow-up in Elmira (white women only), there were fewer pregnancies and births in the home visited than in the group that received the usual services. (This reached statistical significance only for pregnancies among women who, at enrollment, were unmarried and from low socioeconomic status families.) At the 15 year follow-up in Elmira, there were again fewer pregnancies and births in the visited group. (This reached statistical significance among those women who, at enrollment, were unmarried and from low socioeconomic status families.) In Memphis, which only has 24 month follow-up data available, the results are the similar: fewer pregnancies and births among the visited. (The differences in pregnancies reached statistical significance for all, but the births reached statistical significance only for those with high levels of psychological resources.)
Only in one site, Camden, was the Teen Demo able to report fewer pregnancies in the case managed women as compared to the those who received the usual services. (This difference was statistically significant.) In the other two sites, pregnancies were actually higher among the case managed women. Births were higher among the case managed women at all sites.
For the home visiting programs, data on delay of second pregnancy are also available and they show a longer interval between the first and the second birth among the home visited in Elmira at both the 46 month and 15 year follow-ups. (This only reached statistical significance in the 15 year follow-up.)
(It should be noted that the Teen Demo program studied over 3,000 clients, in comparison to approximately 400 in Elmira and over a thousand in Memphis. It is likely that if the differences found in the Elmira and Memphis studies were replicated in larger groups, these differences would be significant.)
REASONS FOR DIFFERENCES
I would like to say that the reasons why the home visiting program had a greater positive impact that the Teen Demo was entirely due to the differences between the two programs. But if I did, I would lose my standing as a health services researcher.
But the populations served by these two programs while similar, but far from identical. The racial/ethnic mix differed in a way that might have favored the home visiting program. The home visiting programs included more women who were not teenagers, which might have favored that program. The percentage of really poor was higher in the Teen Demo program. I suspect that the percentage of women with IQs below 90 was higher in the Teen Demo program. But remarkably, the home visiting program showed its greatest impact on those who were most deprived, those who were unmarried and from low socioeconomic status families.
But these differences in the populations served do not seem sufficient to account for the remarkable differences between the home visiting program in Elmira and Memphis and the Teen Demo in the three sites. Part, if not most, of the differences in results are probably due to the differences in the approach of the two programs. This theory is buttressed by two findings: first, the lower rate of pregnancies and of births in the home visited group, as compared to the group with usual services, is most pronounced among the most disadvantaged in the home visiting program; and, second, program administrators felt that the lower rate of pregnancies at the Camden Teen Demo, as compared to the usual services group, was due the case managers carrying smaller caseloads and being more aggressive and doing more to engage their clients than did the case managers at the other two Teen Demo sites.
It seems likely that the greater success of the home visiting program is due to the overall program approach, as well as to the family planning component in particular. In terms of the overall approach, the use of a nurse and the focus on the home and on social supports probably are elements that should be replicated. The fact that the women in the home visiting program were first contacted before birth and had no prior births might also have favored that program. In terms of family planning, the integration of family planning into an overall plan for the woman's future and the lack of separation between the teaching of family planning and the teaching of other skills seems important. And the same person taught it all. The lack of effectiveness of the workshop approach to changing behavior in relationship to family planning was shown in Newark, which offered the most hours of family planning education, but where those participating in the program had more pregnancies than those who did not. The possibly more directive approach of the nurse is probably another plus, when dealing with teenagers especially.
On the other hand, the Teen Demo should have had an advantage because of its financial disincentives. Research projects differ in respect to finding about financial incentives or disincentives. However, if the programs using the home visiting model are to make a significant impact on teenage subsequent pregnancies throughout the country, they will probably need to be mandatory for those receiving welfare payments. Voluntary programs often have problems enrolling those most in need of their services.
I want to conclude by suggesting that we will not really know how effective the home visiting model is until we try it on populations similar to those studied by the Teen Demo and under the conditions of mandated participation. But my hunch is that home visiting programs implemented as well as the ones were in Elmira and Memphis will have a positive impact even on more difficult populations. To-date no other program has shown such positive results. We certainly should try this one.
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