An ''Epidemic'' of Adolescent Pregnancy?: Some Historical and Policy Considerations

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

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AN "EPIDEMIC" OF ADOLESCENT PREGNANCY? Some Historical and Policy Considerations

Maris A. Vinovskis

New York Oxford Oxford University Press 1988

Oxford University Press Oxford New York Toronto Delhi Bombay Calcutta Madras Karachi Petaling Jaya Singapore Hong Kong Tokyo Nairobi Dar es Salaam Cape Town Melbourne Auckland and associated companies in Beirut Berlin Ibadan Nicosia

Copyright © 1988 by Maris A. Vinovskis Published by Oxford University Press, Inc., 200 Madison Avenue, New York, New York 10016 Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Vinovskis, Maris. An "epidemic" of adolescent pregnancy? Includes index. 1. Adolescent mothers—United States. 2. Pregnancy, Adolescent—United States—History. 3. Pregnancy, Adolescent—Government policy—United States. I. Title. HQ759.4.V55 1988 362.7'96 87-11075 ISBN 0-19-504997-7 Portions of this book previously appeared in: "Young Fathers and Their Children: Some Historical and Policy Perspectives," in Adolescent Fatherhood, Arthur B. Elster and Michael E. Lamb, eds. (Hillsdale, N.J.: Lawrence Erlbaum, 1986), 171-192, reprinted by permission of Lawrence Erlbaum Associates; "An Epidemic of Adolescent Pregnancy? Some Historical Considerations," Journal of Family History VI, No. 2 (Summer 1981), 205-230, reprinted by permission of JAI Press, Inc.; and School-Age Pregnancy & Parenthood: Biosocial Dimensions, Jane B. Lancaster and Beatrix A. Hamburg, eds. (Hawthorne, N.Y.: Aldine De Gruyter, Inc., 1986).

987654321 Printed in the United States of America on acid-free paper

To John N. Erlenborn and James H. Scheuer, for the opportunity to serve on the Select Committee on Population and for demonstrating that even controversial population issues can be resolved on a bipartisan basis if one cares enough.

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Acknowledgments

This book represents nearly a decade of work and reflection during which I have incurred many debts. Some of the chapters were initially researched and drafted while I was on a fellowship from the John Simon Guggenheim Memorial Foundation. Additional financial support was provided by the Taubman Program in American Institutions at the University of Michigan. I am particularly indebted to John Erlenborn and James Scheuer for first giving me the opportunity to deal with the issue of adolescent pregnancy on the U.S. House Select Committee on Population. This work was continued and expanded as a consultant to the Office of Adolescent Pregnancy Programs. Marjory Mecklenburg, the Director of that program, and Ernest Peterson, her deputy, provided invaluable assistance and friendship that I will never forget. Early drafts of some of the chapters were presented at several national academic conferences as well as at seminars at Case Western Reserve University, Harvard University, the University of Michigan, and the University of North Carolina. I am grateful to all of the participants at these sessions for their helpful comments. J. Brooks-Gunn, Lindsay Chase-Lansdale, Frank Furstenberg, Jr., Carl Kaestle, Jeffrey Mirel, Ernest Peterson, James Reed, and Carl Schneider read the entire manuscript of an earlier version of the book and made many excellent criticisms and observations. While I have not been able to incorporate all of their suggestions, the present manuscript is unquestionably much better because of their involvement. Susan Vanderkloot, my teaching and research assistant in the Taubman Program in American Institutions, deserves the highest praise. She twice read and edited carefully the entire book. Without her extraordinary and dedicated assistance, this book could not have been completed.

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The staff at Oxford University Press have been exemplary in their production of this volume. Nancy J. Evans did an excellent job of copyediting the manuscript. I am especially indebted to Sheldon Meyer for his support and encouragement throughout this project. Finally, I want to acknowledge, as always, the help I received from Mary and Andy. Their willingness to tolerate the disruptions in our family life by my involvement in Washington made this book possible. In their own ways, each of them has contributed significantly to helping me understand better how difficult it is to be a caring parent or a child growing up in today's world.

Contents

Introduction Chapter 1 Adolescent Sexuality, Pregnancy, and Childbearing in Early America: Some Preliminary Speculations Chapter 2 An "Epidemic" of Adolescent Pregnancy? The Reactions of the Carter Administration and the 95th Congress from an Historical Perspective Chapter 3 The Origins and Development of the Office of Adolescent Pregnancy Programs Chapter 4 The Parental Notification Controversy Chapter 5 Reassessing the Impact of a Parental Notification Requirement: Some Conceptual and Methodological Observations Chapter 6 Young Fathers and Their Children: Some Historical and Policy Perspectives Chapter 7 Evaluations of Care Programs for Pregnant Adolescents and Young Mothers Chapter 8 Conclusion Notes References Index

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22 47 87 131 157 180 211 218 254 274

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Introduction

During the past twenty years Americans have identified a host of social problems besetting our teenagers: juvenile delinquency, drug use, suicide, child abuse, running away from home, and adolescent pregnancy. Most of these problems are portrayed as unprecedented in our history or at least unprecedented in scope and seen as a serious threat to the well-being of future generations. While acknowledging that the primary responsibility for dealing with these problems lies with parents and local communities, much effort and attention has been directed toward persuading the federal government to enact and fund new programs. It almost seems that a hallmark of our generation is the belief that an essential step toward solving any social problem is to create or designate a federal agency to handle it. These efforts have paid off in the sense that a number of federal initiatives and agencies have emerged to cope with the seemingly growing difficulties facing our children today. However, the actual process of initiating these programs is often unclear or misunderstood and the outcomes are frequently different from what was intended. Little effort has gone into examining why federal programs for troubled teenagers are created or whether they succeed in helping adolescents. How is a particular aspect of teenage life identified as a problem area that requires federal intervention? Who are the individuals and organizations seeking increased government involvement? What are the implicit assumptions about the nature of teenagers and the efficacy of federal programs among the policymakers developing these programs? What role do social scientists play in providing guidance and how do legislators utilize this information? How well do the bureaucrats entrusted with implementing the laws succeed in meeting the expectations of the legislation and in helping teenagers cope with their problems? Have changes in the ways in which society perceives and treats adoles-

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cents affected the difficulties experienced by teenagers or how we try to help them? This book will investigate one of the major problems facing teenagers today—adolescent pregnancy. The so-called "epidemic" of adolescent pregnancy, with four out of every ten girls becoming pregnant as teenagers, is typically portrayed as a recent and unprecedented problem that necessitates massive federal intervention even if this threatens to redefine the relationship between parents and their children. In 1978, Joseph Califano, then Secretary of Health, Education, and Welfare, proclaimed adolescent pregnancy the top domestic priority of the Carter Administration and helped to create a new federal agency and program to deal with this issue. Today federal concern about adolescent pregnancy remains very much alive and is reflected in intense and emotional debates over issues such as whether or not parents have to be notified when their adolescent receives prescription contraceptives from a federally funded family planning clinic. Hundreds of articles and books have addressed the problem of adolescent pregnancy and prestigious academic institutions such as the National Academy of Sciences have set up special panels to study it. In the last ten years adolescent pregnancy has been the focus of nearly a dozen congressional hearings with testimony from scores of expert witnesses. Millions of dollars have been spent on research and most states have set up special service programs to meet adolescent needs. One might therefore question the need for yet another book on a topic that appears to have been so thoroughly researched and discussed. Despite this extensive coverage, however, virtually nothing has been said about adolescent pregnancy from an historical or policy perspective. Due to the unified depiction of adolescent pregnancy as a very recent "epidemic" by almost all policymakers as well as most of the news media, few have probed its historical background. Similarly, even though adolescent pregnancy is such an important domestic issue, little has been written about it from a policy perspective. Although Reagan Administration policies on adolescent pregnancy are very controversial and highly visible, no one has analyzed how the policies were formulated and implemented—in part because of the general inaccessibility of the inter-

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nal workings of the Reagan Administration to most social scientists, who are regarded as hostile liberal critics. Writing about contemporary policies is often difficult because of the limited access one has to the decision making process—especially in a highly controversial and politically sensitive area such as adolescent pregnancy. My task has been eased because I have been a participant-observer to many of the recent developments in Washington. It has also inevitably influenced my perceptions and judgments even though I have tried as much as possible to overcome any personal biases. In any case, it is important for the reader at least to be aware of my personal experiences and the access I have had to policymakers in Washington. Prior to 1978 I did not have much knowledge of or interest in the problem of adolescent pregnancy. Most of my research was on the historical demography of colonial and nineteenth-century America. Although I had done some scholarly work on the politics of abortion in the 1970s, none of my work involved the analysis of adolescent pregnancy either in the past or present. In late 1977, the 95th Congress established the U.S. House Select Committee on Population as a temporary, ad hoc group to investigate domestic and international population problems. Representative James Scheuer (D-NY) was instrumental in its creation and was appointed its chairman. When the Select Committee began looking for staff members with a background in population analysis, my name was mentioned because of my training as a graduate student at the Harvard Population Center and my interest in population policy. Despite my Republican party affiliation, Scheuer hired me as a member of the majority staff. I obtained a leave from the University of Michigan and went to Washington. It turned out that Representative John Erlenborn (R-IL), the ranking Republican member, had not found someone suitable to head up the minority staff. Scheuer suggested that Erlenborn consider me because of my training and Republican orientation. As a result, I was transferred from the majority staff to direct the minority staff. One consequence of this unusual shift in position was that there was little distinction made between the majority and minority staffs on the Select Committee. Both Scheuer and Erlenborn were

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committed to running the Select Committee on a bipartisan basis and Michael Teitelbaum, the Staff Director, shared that philosophy. Indeed, after Teitelbaum decided to return to the Ford Foundation in 1979, I was even offered the opportunity to replace him as Staff Director. As the Deputy Staff Director of the Select Committee on Population, one of my primary responsibilities was to organize and supervise our task force on domestic family planning. Our task force, headed by Representatives Anthony Beilenson (D-CA) and Peter McCloskey (R-CA), held the most extensive set of hearings ever on adolescent pregnancy in 1978, and played a key role in the establishment of the Office of Adolescent Pregnancy Programs (O APP). I had the additional responsibility of working closely with the congressmen and staffs of other House and Senate committees on domestic population matters; thus I became extensively involved in the legislative efforts to create OAPP. Because of the bipartisan orientation of the Select Committee and my own unique position, I worked very closely with lobbyists and population activists from both sides—particularly with those from Planned Parenthood and the Alan Guttmacher Institute who strongly advocated federal domestic family planning programs and were close allies of Scheuer. I also dealt with staff members of the Carter Administration, but never had full access to their activities and private thinking because I was a staff member of a congressional committee. After seriously considering leaving academia for a permanent, full-time career in Washington, I returned to the University of Michigan in 1979 and resumed my normal research as an historian. I did continue my study of the politics of abortion by interviewing both "pro-choice" and "pro-life" leaders and doing statistical analyses of public and congressional voting behavior (because of my academic involvement in this issue, I have never taken a public position on the morality of abortion but have worked closely with both sides as a scholar). I also began to gather materials and do some writing on adolescent pregnancy as the result of my experiences on the Select Committee. After Reagan's election, Marjory Mecklenburg, a moderate "pro-life" activist who had championed services for pregnant teenagers since the early 1970s, was appointed as the Director of the Office of Adolescent Pregnancy Programs (OAPP) in March 1981.

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Through my work in Washington and my research on the politics of abortion, I got to know her. She had testified before the Select Committee on Population and I later interviewed her for my study on the politics of abortion. After her first week as the Director of OAPP, she asked me to come to Washington for one week as a consultant to review the activities of OAPP under her predecessor. Although I was certainly not considered a conservative, I was knowledgeable about adolescent pregnancy policies and could be relied upon to do an objective evaluation of OAPP. My decision to return to Washington as a consultant was based in large measure on my earlier experiences there. I was deeply disappointed that many of the unanimous and bipartisan recommendations of the Select Committee on domestic family planning programs had not been enacted by the 96th Congress nor implemented by the Carter Administration. I was also very concerned that the Reagan Administration might eliminate federally funded family planning programs altogether and felt that individuals such as myself, who at least had some access to the new political appointees, use that opportunity to encourage a more moderate and constructive approach to improving the delivery of family planning services along the lines suggested by the Select Committee. As a result, I looked forward to working with Mecklenburg as I considered her to be a very talented and open-minded political appointee who in the past had publicly endorsed federally funded family planning clinics. Initially, I expected to complete my evaluation of OAPP and then have only infrequent and sporadic contact with OAPP, as I was trying to complete several major academic research projects. My involvement as a consultant, however, expanded as Mecklenburg and I discovered that we agreed on many, though not all, family planning policy issues and as she needed an advisor with strong social science skills once OAPP began its transformation into a small research and demonstration program. In addition, Mecklenburg wanted someone she could personally trust to draft the innumerable memos that are a vital part of the decision making process in the Department of Health and Human Services (DHHS). She was reluctant to delegate that responsibility to her regular staff, many of whom were closely allied to organizations now openly hostile to the Reagan Administration, so I prepared

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the initial drafts of many of the key memos during my four years as a consultant (often going to Washington once or twice a week). In addition, I worked closely with Mecklenburg and her deputy, Ernest Peterson, in formulating and discussing policy options— especially during the first two and a half years. Some of the family planning advocates with whom I had worked as a staff member of the Select Committee on Population were angry that I was willing to be a consultant to the Reagan Administration which they perceived as the archenemy of domestic family planning. Some conservatives distrusted me because of my previous involvement with the Select Committee on Population and my belief that the federal government should provide family planning services to those who cannot afford a private physician. Nevertheless, I continued to have considerable access, though naturally somewhat limited by the circumstances, to both sides while in Washington from 1981 to 1985 (I left when Mecklenburg resigned as the Director of OAPP). Given this extensive involvement in Washington, some have suggested that I should have written more of a memoir than an analysis of policymaking on adolescent pregnancy. Perhaps, but despite my intimate contact with many of the policymakers on both sides of this issue and my experiences both on the Hill and in the executive branch, I was always only an influential staff member rather than the one who made the decisions. In addition, much of the knowledge I have comes from gleaning information from written records usually inaccessible to most outsiders or discussing the issues with the participants rather than witnessing the particular events myself. Furthermore, because of the unique circumstances of my involvement and my historical orientation, I have always felt and been perceived as somewhat of an outsider in Washington throughout the past decade. I hope this detachment has allowed me to provide some different and useful perspectives on adolescent pregnancy policy without sacrificing the objectivity one strives for as a social scientist. This book consists of a series of essays that provide some historical and policy perspectives on the recent so-called "epidemic" of adolescent pregnancy. The essays are intended to give us a broader and more historical sense of recent changes in adolescent pregnancy and to show how different policymakers in Washington have

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defined and dealt with this problem—particularly in the 1970s and 1980s. The book does not pretend to be either a detailed history of adolescent pregnancy or a comprehensive review of all aspects of federal policymaking on this issue. Instead, it should be regarded as a modest, exploratory foray that tries to open up new areas of inquiry and advocates taking an historical perspective on contemporary social problems. Chapter One analyzes adolescent sexuality, pregnancy, and childbearing in early America. Were these adolescent behaviors as widespread in colonial and nineteenth-century America as they are today? Were they seen as serious social problems? And does knowledge about trends in adolescent sexual activity, for example, have any policy implications for the current debates over the seemingly irreversible high rates of premarital sexual activity among teenagers today? The next chapter scrutinizes the reactions of the Carter Administration and the 95th Congress to the "epidemic" of adolescent pregnancy. Was adolescent pregnancy in the second half of the 1970s really an unprecedented epidemic? How did policymakers perceive and define the problem of adolescent pregnancy during these debates? Why did some legislators see the problem as one of reducing unintended pregnancies while others viewed it as helping young mothers and their children? And what are some of the research opportunities and needs in this area from a twentiethcentury perspective? The origins and development of the Office of Adolescent Pregnancy Programs (OAPP) are traced in the third chapter. The initial efforts by Senator Edward Kennedy (D-MA) to create a federal program for pregnant teenagers and young mothers are detailed, while particular attention is paid to the unsuccessful legislation for school-age mothers in 1975. Drawing upon that earlier legislation, the 95th Congress established OAPP in 1978. The chapter then analyzes the functioning of OAPP under its first director, Lulu Mae Nix, during the Carter Administration and follows the attempted redefinition of the problem of adolescent pregnancy by Senator Jeremiah Denton (R-AL) and the Reagan Administration by considering the changes in the 1981 legislation governing OAPP. Chapter Four provides an historical look at the parental notifica-

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tion controversy. Changes in public attitudes and in laws governing the distribution of contraceptives to unmarried teenagers are examined. The efforts within the Reagan Administration to require parents to be notified whenever teenagers under eighteen receive prescription contraceptives from a federally funded family planning clinic are examined here using hitherto unavailable internal memos and my personal observations of the activities of Marjory Mecklenburg, the first director of OAPP under the Reagan Administration. The reasons for the failure of the Reagan Administration to implement a parental notification requirement can only be assessed by taking into account the role of Congress, the family planning lobbyists, public opinion, and the involvement by the judiciary. Chapter Five analyzes the parental notification controversy from another perspective. The Alan Guttmacher Institute (AGI) analysis of the impact of the proposed regulations was accepted by both sides as the key social science study on this issue, but each side cited those results selectively. Since no one has investigated the assumptions or procedures of this classic study, Chapter Five examines the methodology employed and recalculates the AGI estimate of the likely impact of a parental notification requirement. The reanalysis of the AGI study also raises questions about how social science research is used in highly controversial areas—especially when the research is done by a group deeply involved in that debate. Almost all of the discussions about teenage pregnancy today focus exclusively upon the female adolescent and her child. Very little, if any, attention is paid to the young father. In Chapter Six the changing role of the father is traced from the colonial period to the present. The absence of the role of the father from consideration among policymakers in the 1970s is documented and the recent interest of the Reagan Administration in the responsibilities of the father is considered. The chapter traces the emergence of this new issue in the arena of adolescent pregnancy policy debates as the Reagan Administration and its supporters seek to redefine existing priorities. Unlike most other social programs, one of the special characteristics of the federal efforts to help pregnant teenagers is the strong interest and emphasis on the evaluation of the service programs for

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pregnant adolescents and young mothers. Indeed, recent legislation on adolescent pregnancy created a small research and demonstration program rather than the large-scale service delivery program envisioned by the Carter Administration. In addition, private foundations have poured millions of dollars into evaluations of programs designed to help pregnant teenagers and young mothers. Yet the quality of these evaluations leaves much to be desired and points to the difficulties of doing applied social science research. This chapter critiques the major evaluations of care programs for pregnant teenagers and adolescent mothers and suggests ways of improving evaluation research. The book concludes with an overview of the problem of adolescent pregnancy, reviews the efforts to solve this problem, and suggests ways of proceeding in the future. It also addresses the role of social scientists in the formulation and implementation of policies, and considers the importance of an historical perspective in dealing with contemporary social problems.

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AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

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1 Adolescent Sexuality, Pregnancy, and Childbearing in Early America: Some Preliminary Speculations

While adolescent sexuality, pregnancy, and childbearing are now receiving an extraordinary amount of attention, little historical research has been done on these issues. On the one hand, historians of human sexuality and fertility usually do not distinguish between the behavior of adolescents and adults (Vinovskis, 1981b; Wells, 1975). On the other hand, most of the historical studies of teenagers do not analyze adolescent sexuality and childbearing (Kett, 1977). Were adolescent sexuality, pregnancy, and childbearing seen as problems in the past? We might suggest a whole host of circumstances that could have been present to influence early Americans and leave them with different views on these issues. Perhaps the age at menarche for girls is much lower today so that few adolescents experienced early childbearing in colonial America. Or, if most women married at an early age as some historians have argued, then adolescent childbearing may not have appeared to be a particular problem. Even if girls were fecund at an early age and married in their teens, did they engage in premarital sexual activity? Maybe the Puritans were so successful in controlling the behavior of early Americans that premarital sexual activity never became a serious problem. Finally, some scholars assert that the 3

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concept of adolescence as a distinct and emotionally tumultuous phase of development is only a twentieth-century phenomenon. If our ancestors did not make any distinctions between teenagers and adults, then their lack of attention to adolescent behaviors seems understandable. Exploring the issues of adolescent sexuality, pregnancy, and childbearing in the past presents difficulties because of the lack of historical studies. As a result, this chapter will of necessity only provide an exploratory and cursory overview. Yet by bringing together the available scattered pieces of information, one can at least delineate some of the basic issues as well as provide some tentative answers. Although the chapter will try to present comparative data whenever possible, its focus and evidence are mainly from New England in the seventeenth, eighteenth, and nineteenth century.1 Age at Menarche and Marriage Americans in the past may have paid little attention to adolescent sexuality, pregnancy, and childbearing because these experiences lacked saliency. For example, if the historical age of sexual maturity was much higher in the past, then most teenagers would not have been concerned about becoming pregnant or bearing children. We should not assume that our ancestors matured sexually at the same ages as we do today—especially as considerable evidence exists of a secular decline in the age of menarche (Wyshak and Frisch, 1982; Tanner, 1965; Brundtland and Walloe, 1976). The age at menarche is particularly important for understanding family life in early America because the Puritans did not consider a marriage valid unless both partners were sexually mature and the marriage had been consummated. In fact, the Puritans considered the inability to have sexual intercourse grounds for annulling a marriage (Laslett, 1971). Therefore, the age at menarche set the lower limit for the age at which girls could marry in colonial America. Only limited information of varying quality on the age at menarche in the past exists, yet enough data have survived to allow some general observations. While girls today experience menarche at about 12.8 years, their American and European counterparts a

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century ago had to wait several more years. Grace Wyshak and Rose Frisch (1982) recently reviewed 218 reports from 1975 to 1981 on the age of menarche in Europe (including 220,037 individuals). They found that in the early nineteenth century the age of menarche may have been as high as seventeen or eighteen. However, the age at menarche in Europe declined by two or three months per decade, with the greatest decline occurring in the Scandinavian countries and the smallest occurring in France. The age at menarche appears to be influenced by many different factors, such as fatness in adolescence, physique, health status, genetics, and socio-economic status (Johnson, 1974). Nutrition remains the best-established factor, however, with severe malnutrition delaying menarche (Frische and McArthur, 1974). Because age at menarche appears to be closely linked with the environmental conditions under which children develop, any attempt to extrapolate directly from the age at menarche in Europe to colonial America is highly questionable. In fact, when information on the ages at menarche can be found for the United States in the late nineteenth and twentieth century, those figures are consistently lower than the European averages. Data from the United States indicate a secular decline in age at menarche from 14.75 years in Bowditch's study of 1877, to about 14 years at the turn of the century, and to 12.8 years in 1947. Since that time the decline in age at menarche in the United States seems to have stopped (Wyshak and Frisch, 1982). Although we have reasonable estimates of the age at menarche in the United States in the last quarter of the nineteenth century, we do not have comparable data for the seventeenth and eighteenth centuries. We do have some estimates of the age of menarche among slaves for the antebellum period. A recent analysis by Robert Fogel and Stanley Engerman (1974) of antebellum slavery asserts that plantation owners did not breed their slaves in a deliberate attempt to maximize their profits. As proof, they cite the relatively late age at first birth among slaves compared with their early age of menarche. Critics of Fogel and Engerman quickly challenged many of their assumptions including their discussion of the age at menarche (Gutman and Sutch, 1976). James Trussell and Richard Steckel (1978) recalculated the ages at menarche and first birth for antebellum slaves using probate and

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plantation records. Based on an estimate of the caloric intake of slaves as well as on an analysis of spurts in their heights, Trussell and Steckel conclude that menarche occurred at least by age fifteen and probably even earlier. Debates over the advisability of older girls' attending colleges or universities in the nineteenth century offer another indirect indicator of the age at menarche among the white population. Many nineteenth-century physicians such as Horatio Storer described menstruation as "periodic infirmity . . . temporary insanity" (cited in Walsh, 1977: 111). Similarly, Dr. Edward Clarke warned that because the uterus was connected to the central nervous system, women should not be subjected to the same education as males. Energy expended on intellectual pursuits would necessarily arrest the sudden but normal spurt of reproductive development at the time of puberty. The results of female education under these circumstances would be "monstrous brains and puny bodies; abnormally active cerebration and abnormally weak digestion; flowing thought and constipated bowels" (Clarke, 1873: 41). Although others challenged the advice of doctors such as Storer and Clarke, the debates implied that girls experienced menarche at about fourteen or fifteen—quite close to the figure suggested by the Bowditch study as well as by the estimate of menarche among antebellum slaves. If menarche occurred around age fourteen or fifteen in nineteenth-century America, is it possible to make any inferences about the seventeenth and eighteenth centuries? Unfortunately, we do not have any detailed studies of the age at menarche for that period, but the investigations of nutrition and wealth suggest that American colonists fared better than their European counterparts (Fogel, 1986; Jones, 1980). Furthermore, because the height of individuals reasonably reflects their nutritional experiences, the fact that the average height of army enlistees in the United States from 1789 to 1894 remained fairly constant (Soltow and Stevens, 1981) reinforces the idea that little change in nutrition had occurred between the late eighteenth and nineteenth century.2 Therefore, one might speculate that the onset of menarche in colonial America was around age fifteen or sixteen though no substantial direct evidence on this has been thus far uncovered.3 While menarche signified the sexual maturity of girls to early

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Americans, it did not mean that these young women were all immediately capable of childbearing. Adolescents typically experience a period of subfecundity that reduces fecundability considerably (Talwar, 1965; Trussell and Steckel, 1978). Furthermore, adolescent subfecundity and age at menarche may be related, with the period of reduced fecundability decreasing as the age at menarche declines (Frisch, 1975). Therefore, even if adolescents in early America experienced menarche by age fifteen or sixteen, we should not expect most sexually active adolescents to bear children at those ages. Having speculated about the age of menarche, we should now turn to the age at marriage as another potentially important factor affecting the lives of adolescents in the past. If teenagers married soon after puberty, then many of the problems currently associated with premarital adolescent sexuality, pregnancy, and childbearing (Card and Wise, 1978; Furstenberg, 1976; Moore and Caldwell, 1977) would not have been historically present. In many societies marriage signifies the transition from being dependent upon one's own family to establishing a separate household. In Western Europe in the sixteenth and seventeenth century, individuals usually did not marry unless they were economically able to create and maintain their own home. Under these circumstances, an early marriage was usually considered desirable as it signified relative independence from others and the start of one's own family (Stone, 1977). The requirement of being able to maintain an independent home forced many individuals to postpone their marriages or to remain single throughout their lives. J. Hajnal (1965) characterized this as the "European marriage pattern" with men marrying in their late twenties and women in their early or mid-twenties.4 As a result, adolescents commonly went through their teenage years without experiencing sexual intercourse or bearing a child (Stone, 1977). Although economic scarcity generally precluded early marriages in Western Europe in the seventeenth and eighteenth centuries, it should not have been a major deterrent in the New World where economic opportunities abounded (Walton and Shepherd, 1979; Jones, 1980). Indeed, early historians of the American family such as Alice Earle (1895) and Arthur Calhoun simply assumed that girls married at a very young age. "The early Puritans

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married young. . . . Girls often married at sixteen or under. Old maids were ridiculed or even despised. A woman became an 'ancient maid' at twenty-five" (Calhoun, 1960: 67). Thus, while current analyses of adolescents almost uniformly point to the problems caused by early marriages and childbearing, these older studies suggest just the opposite—colonial Americans perceived women who did not marry in their teenage years as unfortunate and disadvantaged. The early historians of the family relied almost exclusively on literary evidence for estimating the age at first marriage in colonial America. However, in the late 1960s demographic historians such as John Demos (1970), Philip Greven (1970), and Kenneth Lockridge (1970) tried to determine empirically the age at first marriage by reconstituting the lives of the early settlers from local town and church records in New England. They discovered (to everyone's surprise) that few New England girls had married as early as age fifteen or sixteen. The general contours of the age at first marriage in colonial New England are now fairly clear. Compared with their counterparts in England, men and women married at younger ages. Overall, women married in their very early twenties and men married during their late twenties. The age at which women married gradually increased from the seventeenth to the eighteenth century while the age at which men married experienced a corresponding decrease (Vinovskis, 1981b). Although the data on the age at first marriage for the nineteenth century remain scarce, they suggest a slight increase. Thus, the mean age at first marriage in Massachusetts from 1845 to 1860 was about twenty-six for males and twenty-four for females. Only 3.6 percent of native-born women and 4.7 percent of foreign-born women ages 14 to 19 were married illustrating the relative infrequency of marriage among teenagers in the nineteenth century (Massachusetts, 1887). Thus, at no time during the colonial or early national period did large numbers of very young adolescents regularly marry in New England.5 While there has been no comprehensive examination of trends in the ages at marriage in New England, some tentative explanations can be offered. Settlers to the New World brought with them the cultural expectations of a late age at first marriage. However, favorable economic conditions allowed them to marry sooner than

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their counterparts in the Old World. In addition, the relative scarcity of women in the early decades of settlement may have encouraged men to marry younger women. As the eighteenth century progressed and the sexual imbalance corrected itself, male colonists no longer had to take a young wife (Jones, 1981; Norton, 1981; Vinovskis, 1981b). While some Americans had praised the virtues of very early marriages, few of them personally followed that advice. Indeed, in the nineteenth century many women increasingly felt that they should enjoy their youthful independence for as long as possible before settling down to the responsibilities of married life (Degler, 1980; Rothman, 1984). The ages at menarche and first marriage in early America suggest that most adolescents experienced puberty several years before they married. If they did not encounter some of the same problems associated with adolescent sexuality, pregnancy, or childbearing that haunt today's teenagers, it was not because they did not experience a period of time between sexual maturity and marriage. In fact, because the age at first marriage rose from the seventeenth to the nineteenth century for women and the age of menarche somewhat declined, the amount of time adolescents spent in this transition phase actually increased. Adolescent Premarital Sexual Activity During the 1970s adolescent premarital sexual activity increased dramatically. Melvin Zelnik and John Kantner (1980) estimate that the percentage of never-married metropolitan area females ages 15 to 19 who have engaged in sexual intercourse increased from 27.6 percent in 1971 to 46.0 percent in 1979. While some policymakers have reluctantly accepted such high rates of sexual activity as a given and have mainly focused their energies on ways on improving contraceptive use among teenagers, others, like former Senator Jeremiah Denton (R-AL) are trying to reverse the trend in adolescent sexual activity. We might also be interested in whether sexual activity among adolescents has varied historically and in the causes of those fluctuations in behavior. Many Americans simply assume that once a society has reached high levels of early premarital sexual activity, that trend cannot be reversed.

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One usually cannot directly measure sexual activity in the past. We can, however, estimate premarital sexual behavior trends in societies without modern contraceptives by calculating the percentage of first births born six or eight and a half months after marriage. Naturally, only a small proportion of premarital sexual activity results in the birth of a child, but the information provided by this index of premarital pregnancies can be useful for approximating shifts in premarital sexual activity in early America (Stone, 1977: 607-609). Daniel Smith and Michael Hindus (1975) assembled premarital pregnancy data from 5,665 marriages in the United States in the seventeenth, eighteenth, and nineteenth century (see Figure 1-1). The sample is heavily biased toward rural New England and onethird of the cases come from Hingham, Massachusetts. Nevertheless, this series provides us with the most comprehensive and systematic information currently available on premarital pregnancies in early America. This series on premarital pregnancies indicates wide fluctuations over time—from a low proportion of premarital pregnancies in the seventeenth century (under 10 percent of first births) to a high percentage in the second half of the eighteenth century (nearly 30 percent). Although fecundability, pregnancy wastage, contraceptives, induced abortions, and illegitimacy lowered the extent of premarital pregnancies, it is unlikely that these factors can account for the dramatic trends over time (Smith and Hindus, 1975). The cycle of premarital pregnancies in America resembles the English and French patterns. The United States, however, differs in that it experienced a sharp decline in the early nineteenth century whereas Europe experienced that decline a half century later (Laslett et al., 1980). To consider the trends in adolescent premarital pregnancies over time, we need to separate the data by the age at marriage of the women. Unfortunately, we only have such historical data from two Massachusetts communities—Andover and Hingham (see Figures l-2a and l-2b) (Smith and Hindus, 1975). The age-specific pattern in those communities roughly corresponds to the trend in total premarital pregnancies. Interestingly, during most of this time period, the rate of teenage premarital pregnancies was significantly higher than for older women—per-

Adolescent Pregnancy in Early America

11

Source: Smith and Hindus (1975)

FIGURE 1-1. Premarital Pregnancies in America

haps reflecting a desire among women to postpone matrimony unless they were forced to marry by an unintended pregnancy. The relatively low rate of adolescent premarital pregnancies in Hingham before 1720 may in part reflect teenage subfecundity—particularly if the age of menarche in seventeenth-century Hingham was higher than in the eighteenth or nineteenth century (Smith and Hindus, 1975). It may also reflect, however, tighter controls on adolescent rather than adult sexual behavior by the Puritans during the seventeenth century.6 The low rate of premarital pregnancies in the seventeenth century does not seem very surprising because we have always assumed that Puritans strongly opposed premarital and extramarital sex. New England Puritans were not hostile to sex; in fact they regarded it as an essential and welcome part of matrimony. However, they stressed the need for self-control and self-denial in sexual matters for unmarried individuals (Morgan, 1966; Thompson, 1986). New England Puritans in the seventeenth century demanded that the entire community conform to the exemplary moral codes

12

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

Source: Smith and Hindus (1975)

FIGURE 1-2A. Percentage of Premarital Pregnancies in Hingham by Age drawn up by the first settlers. Civil magistrates or ministers quickly and publically chastized sexual offenders. One source estimates that as late as the 1670s well over one-half of the guilty couples involved in premarital pregnancies in Essex County, Mass., found themselves convicted and punished (Smith and Hindus, 1975). Whereas sexual activity prior to marriage had been quite common in the fifteenth and sixteenth centuries in England, Puritans in England and the New World succeeded in greatly reducing that behavior (Stone, 1977).7

Adolescent Pregnancy in Early America

13

Source: Smith and Hindus (1975)

FIGURE 1-2B. Percentage of Premarital Pregnancies in Andover by Age

Perhaps the most surprising result of the data by Smith and Hindus (1975) is the rapid rise and the peak of premarital pregnancies in the late seventeenth and eighteenth century. By the second half of the eighteenth century, nearly 30 percent of first births occurred within eight and one half months of the marriage. The rise in premarital pregnancies was not peculiar to the United States. In England the loosening of popular convention about sexual behavior quickly followed the restoration of the monarchy in 1660 as secularism replaced Puritanism (Stone, 1977). In New England observers noted a steady and quite visible erosion of church and civil opposition to premarital sexual activities. In Essex County, for example, the number of civil prosecutions for fornication dropped and the penalty ranged from corporal punishment to the payment of a fine (Smith and Hindus, 1975). In Middlesex County, Massachusetts, signs of moral irresponsibility in fornication cases increased starting in the 1660s (Thompson, 1986). When prominent church leaders such as Jonathan Edwards in the eighteenth century tried to punish the lax moral standards of their parishioners, they found they could no longer count on the support of their congregations or the rest of the community (Tracy, 1979). Simultaneous with the unwillingness of civil or church authorities to punish cases of bridal pregnancies, parents gradually lost their ability to "persuade" their children to marry according to parental wishes (Smith, 1973).8 In the absence of concerted communal or familial efforts to curb premarital sexual activity, a general loosening of sexual behavior

14

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

occured among early Americans. Sexual intimacy returned as a normal part of courtship behavior and practices such as bundling became more common (Stiles, 1934). The promise to marry rather than the marriage ceremony itself often led to sexual intercourse among couples. As long as the community was not saddled with the financial burden of illegitimate children, citizens tolerated premarital pregnancies. The result was not a breakdown of sexual mores in the early Republic but a shift in the definition of appropriate behavior between individuals in love (Ulrich, 1982). While some consensus exists on the low level of premarital pregnancies in the seventeenth century and their increase during the eighteenth century, scholars disagree over the pattern in the nineteenth century. Edward Shorter (1975: 334), looking at Western Europe and the United States, rejects the Smith and Hindus (1975) data as overrepresenting the experience of a few New England towns and dismisses their argument that premarital intercourse declined in the nineteenth century. Instead, Shorter (1975: 80) concludes that: The central fact in the history of courtship over the last two centuries has been the enormous increase in sexual activity before marriage. Before 1800 it was unlikely that the typical young woman would have coitus with her partner—certainly not before an engagement had been sealed, and probably not as a fiancee either. But after 1800 the percentage of young women who slept with their boyfriends or fiancees rose steadily, until in our own times it has become a majority.

Others have challenged Shorter's portrayal of the trends in premarital pregnancies and out-of-wedlock births and his interpretation of them. Shorter sees the rise in premarital sexual activity in the late eighteenth and nineteenth century as an entirely new phenomenon; other scholars suggest that it was already quite high in the fifteenth and sixteenth centuries (Laslett et al., 1980). In addition, though Shorter dismisses the work of Hindus and Smith (1975) as unrepresentative and incorrect, he does not produce any evidence to counter it. Therefore, we have no reason at this time to doubt that the rise and decline in premarital pregnancies in the United States did not occur about half a century earlier than in

Adolescent Pregnancy in Early America

15

Western Europe.9 Finally, whereas Shorter explains much of the rise in sexual activity as the result of changes in the lives of young women fostered by urban and industrial development, others have questioned his interpretation of these women's lives and have pointed to the fact that similar shifts in sexual activity simultaneously occurred in agricultural and rural areas (Tilly and Scott, 1978). Assuming that Smith and Hindus (1975) are correct in dating the decrease of premarital pregnancies in America during the early nineteenth century, how can we account for this change? The answer probably lies in the development of a nineteenth-century attitude toward sex that accepted sexuality within marriage, but strongly condemned it outside of marriage. Colonial Americans had placed great stress on the public censure of deviants, but the early nineteenth-century reformers devoted more of their efforts to instilling the values of self-control and self-discipline.10 In addition, the waves of religious revival that swept across America in the early nineteenth century preached the gospel of sexual abstinence before marriage and involved teenagers as well as adults.11 Whereas religion did not appear to be a major factor in preventing premarital pregnancies in the eighteenth century, it now assumed a much more important role.12 Medical writings reinforced the aversion to sex prior to marriage by warning adolescents of the dangers of dissipating their strength and vitality through sexual activity or masturbation (Bullough and Voight, 1973). Even married couples were urged to practice moderation in their sexual relations lest they damage themselves by excessive indulgence. Some writers specifically condemned early marriages because such arrangements would injure both the maturing parents and their offspring. An anonymous clergyman (Physiology of Marriage, 1856: 22) in Massachusetts cited an eminent British writer in condemning the dangers of an early marriage: Dr. Johnson proceeds to say that for every year the female marries below the full age of twenty-one, "there will be, on an average, three years of premature decay of the corporeal fabric, and a considerable abbreviation of the usual range of human existence." Thus, if she marries at eighteen, instead of twenty-one, there will be, according to this estimate, which he insists is "a fair one," nine years of

16

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY? premature decay; and, if she marries at sixteen, instead of twentyone, her physical decline will be hastened no less than fifteen years!

Perhaps, most important of all, prohibitions against sex prior to marriage became part of a broader ideology of what constituted respectability for women in the nineteenth century. A girl transgressing from this ideal faced punishment by social ostracization. The notion of the "fallen" woman became so prevalent that any sexual experience prior to marriage contaminated a woman and made her a less desirable marriage partner (Berg, 1978). In addition, female delinquency became associated with sexual impropriety and thus reinforced the link between early sexual activity and deviance (Sedlack, 1980; Schlossman and Wallach, 1980; Brenzel, 1975, 1980). Of course, not everyone lived up to the new expectations of sexual abstinence prior to marriage and many engaged couples still became sexually intimate. The penalties for such behavior, however, seemed much more severe than in the eighteenth century (Parkes, 1932; Erikson, 1966). While the diffusion of contraceptive information in the early nineteenth century may have reduced the number of premarital pregnancies, the stigma attached to an outof-wedlock birth probably led to many induced abortions among single women (Mohr, 1978). Furthermore, as the nineteenth century progressed and the value of sexual abstinence became routinely accepted, a real decline in premarital sexual activity probably did occur, rather than just an increase in the effectiveness of contraceptives or the use of abortion (Smith and Hindus, 1975). Adolescents and the Change in Sexual Activity and Pregnancy We have established thus far that most adolescent girls probably were sexually mature by the ages of fifteen or sixteen in early America, but that they usually did not marry until age twenty. We have also detected wide fluctuations in premarital sexual activity for both adolescents and adults, although the explanations for these changes are still quite sketchy. Now we must turn to the issue of whether Americans in the seventeenth, eighteenth, or nine-

Adolescent Pregnancy in Early America

17

teenth century regarded adolescence as a unique developmental period in the life course. Philippe Aries (1962) has argued that because children were treated as miniature adults in the past, no special distinctions would have been made for adolescents. This notion was accepted by colonial historians such as John Demos (1974: 428): Colonial society barely recognized childhood as we know and understand it today. Consider, for example, the matter of dress; in virtually all seventeenth-century portraiture, children appear in the same sort of clothing that was normal for adults. In fact, this accords nicely with what we know of other aspects of the child's life. His work, much of his recreation, and his closest personal contacts were encompassed within the world of adults. From the age of six or seven he was set to a regular round of tasks about the house or farm (or, in the case of a craftsman's family, the shop or store). When the family went to church, or when they went visiting, he went along. In short, from his earliest years he was expected to be—or try to be—a miniature adult.

If Demos is correct about childhood in early America, then the notion of adolescents as separate or distinct from adults was simply missing from that society. Yet while Demos is correct in saying that the Puritans did not treat their children the same as we do today, he was incorrect in suggesting that New Englanders did not distinguish between adolescents and adults. In fact, Puritans commonly referred to children roughly in the age group fifteen to twenty-one or twenty-four as youths and treated them somewhat differently, depending upon the issue, from older adults (Stannard, 1975; Kaestle and Vinovskis, 1978). Early Americans did differentiate between youths and adults, but that distinction was general and not closely linked to exact chronological age. Colonial Americans did not pay much attention to age, but focused instead on other attributes of individuals. It is only in the late nineteenth century when age-grading in schools became more prevalent that chronological age and developmental attributes began to be tied together. Historians are still debating whether adolescence as a phase of life as we know it today existed in the past. According to Demos and Demos (1969), while the concept of youth as a general period

18

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

of semi-dependency existed in the first three-quarters of the nineteenth century, nothing fully resembling today's adolescence existed at that time. But the transformation of America from an agricultural to an urban-industrial society during these years created sharp discontinuities in the lives of children and prepared an environment in which adolescence as a stage of life eventually could develop. Others have challenged this interpretation by pointing out that in the seventeenth century youths experienced many of the same emotional impulses and tensions that we associate with adolescence today (Thompson, 1984, 1986). Some locate the emergence of adolescence in the eighteenth century (Beales, 1975; Hiner, 1975). At the present time this debate cannot be resolved; but it appears that in the seventeenth, eighteenth, and nineteenth century contemporaries only loosely defined the teenage years and based their observations more on economic and social status rather than chronological age (Juster and Vinovskis, forthcoming). Most of the studies today (Card and Wise, 1978; Furstenberg, 1976; Moore and Caldwell, 1977) suggest that early marriage and childbearing are deterimental to the parents—especially the mother. Did adolescents who married early in the past suffer from any adverse consequences? Were their early marriages regarded as undesirable by contemporaries? In the seventeenth and eighteenth centuries no strong bias against early marriages or childbearing existed as long as the individuals involved were sexually mature, capable of supporting an independent household, and had the approval of their parents. Couples did tend to postpone marriage until the woman was about twenty years old, but individuals who married earlier were not ostracized or punished. A growing feeling that children should not marry too early did begin to emerge in the nineteenth century. Physicians cautioned young men and women against engaging in sex while their bodies were still growing because sexual activity was thought to drain the body of vital energy necessary for normal growth (Walsh, 1977; Bullough and Voight, 1973). In addition, the emphasis on receiving a common school education, especially for males, made early marriages less desirable from an educational perspective.13 Finally, a growing number of young women felt that they should postpone their marriages in order to enjoy their youthful independence and to earn money in the textile mills or teaching profession. While

Adolescent Pregnancy in Early America

19

most young women only worked for a few years before finally getting married and having a family, even middle-class girls who did not need to work in order to support their parents or to put aside money for their dowries cherished this period of independence (Mason et al., 1978). If early marriage and childbearing did not evoke cries of social disapproval in the past, did it handicap those individuals later in life? Though we do not have any longitudinal information on the effects of early marriage and childbearing for the seventeenth, eighteenth, or nineteenth century, we can speculate on what such data might reveal by considering whether education was really necessary or useful for success. Certainly educators like Horace Mann believed that only those who completed a common school education would achieve success in nineteenth-century America and most educational historians have agreed with him (Vinovskis, 1970). Thus, children of foreign-born parents who did not receive as much education as those of native-born parents are seen to have suffered when they attempted to advance in their careers (Thernstrom, 1964). Yet Harvey Graff (1979) has recently challenged this idea by arguing that literacy in early America was not essential or even especially helpful in achieving material success. Again, we cannot, at this time, settle the debate over the economic productivity of education in the past, but I suspect that education had more value than Graff suggests. Nevertheless, education, beyond the ability to read and write, probably brought fewer financial rewards in the nineteenth century. A young parent denied that opportunity because of early marriage and childbearing would not be as disadvantaged as their twentieth-century counterparts. Furthermore, because most women did not continue employment outside their own households after marriage in the nineteenth century, early withdrawal from school probably caused only minimal disadvantage. Certainly common school reformers in the mid-nineteenth century made no effort to encourage or even to allow pregnant teenagers to continue their education and did not indicate that the girls' lack of access to that schooling would handicap them later. If early Americans did not express disapproval of early marriages or childbearing, did they oppose sexual intercourse among adolescents beyond condemnation of premarital sex in general? In other words, were teenagers who engaged in premarital sex singled

20

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

out for attack more often than adults when magistrates or ministers condemned such practices? Although ministers in the early nineteenth century frequently addressed teenagers on the sins of premarital sexual behavior, it appears that they hoped to reach the youth audience and rarely focused on the especially sinful and harmful nature of premarital sex among adolescents. Thus, the general societal attitudes toward premarital sex played a much larger role in determining how young people would be treated than any special view of adolescents. One interesting perspective on whether sexual activity was viewed differently among adolescents than adults can be found in public reactions to prostitution in nineteenth-century America. As reformers denounced the evils of prostitution and sought to eradicate it, did they pay particular attention to teenage prostitutes? And, in appealing to the sympathy of the public and the magistrates, did they evoke the image of the particular vulnerability of the young prostitute? According to the recent work of Barbara Hobson (1981) on prostitutes in antebellum Boston, juvenile prostitution was not a focal point of discourse among reformers. Moral reformers, administrators in public and private agencies, and police and court personnel who voiced concern about prostitution emphasized women's vulnerability to sexual exploitation because of their dependency on men. Anti-prostitution campaigns did not particularly emphasize the age of the woman, nor were the early anti-prostitution laws age-specific. It is unclear at what period juvenile prostitutes were singled out as especially warranting pity and attention, but it may have occurred only in the late nineteenth and early twentieth century. Thus, the evidence from religious leaders as well as from anti-prostitution activists supports the notion that premarital sexual intercourse among adolescents was not seen as especially problematic compared to the same behavior among adults prior to the mid-nineteenth century.14 Conclusion Adolescent sexuality, pregnancy, and childbearing were not seen as particularly important problems and issues in early America.

Adolescent Pregnancy in Early America

21

Even though adolescent girls reached sexual maturity by age fifteen or sixteen, most of them postponed marriage until they were at least twenty. Those who did marry early and started their families as teenagers did not seem to suffer either public condemnation or limited opportunities in their subsequent lives. While premarital sexual activity encountered strong opposition in the seventeenth and nineteenth centuries, adolescents do not appear to have been singled out when this behavior was denounced. Americans in the past paid little attention to the issues of adolescent sexuality, pregnancy, and childbearing because they occurred so infrequently compared to our current situation. Contrary to the popular image of the past, few girls married or had children as young teenagers in early New England. Furthermore, although the Puritans did distinguish between youths and adults, they did not focus on that distinction when judging the suitability or advisability of sexual activity, marriage, or childbearing. Although we do not perceive or treat our contemporary problems of adolescent pregnancy the same as in the past, we can benefit from an historical perspective on this issue. For example, during the debates in the U.S. Congress over adolescent pregnancy in 1978 and 1981, considerable disagreement emerged over whether the recent increases in sexual activity among teenagers could actually be reversed (Vinovskis, 1981a). A glance at the fluctuations in the rates of premarital pregnancy in America during the past 350 years should be enough to convince anyone that such increases can be reversed because nineteenth-century Americans succeeded in greatly reducing their premarital sexual activity. Whether the mechanisms of social control used in the early nineteenth century would be deemed acceptable by most Americans today is another question. Yet an understanding of the relationships between broader societal changes and more specific aspects of life such as adolescent premarital behavior may help us to see our own problems within a more appropriate framework and context.

2 An "Epidemic" of Adolescent Pregnancy? The Reactions of the Carter Administration and the 95th Congress from an Historical Perspective

As we have seen in the previous chapter, adolescent pregnancy was not regarded as a serious problem in colonial and nineteenthcentury America. Indeed, even thoughout much of the twentieth century most policymakers did not view adolescent pregnancy as an issue that required special attention and government assistance. Yet by the second half of the 1970s the Carter Administration and the 95th Congress had identified teenage pregnancy as a serious domestic problem. Many people assume that a substantial increase in adolescent pregnancy and childbearing during the 1960s and 1970s caused the sudden concern about adolescent pregnancy. Indeed, most commentators characterize adolescent pregnancy as a recent "epidemic" that threatens the traditional American family. Yet as we shall see, the demographics of adolescent pregnancy cannot account for our recent discovery of this problem. The emergence of adolescent pregnancy as a major social problem during the 1970s is evidenced by the enactment of the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 by 22

An "Epidemic" of Adolescent Pregnancy?

23

the 95th Congress. An analysis of this legislation allows us to examine the debates over the causes and proposed solutions for adolescent pregnancy. It also gives us an opportunity to develop a social and demographic context for understanding recent trends. The passage of this legislation illustrates how the failure of the participants to take a broad historical perspective in this debate limited the options they explored. Therefore, this chapter will review the efforts during the Carter Administration of Washington policymakers to deal with adolescent pregnancies, consider how this issue might have profited from an historical perspective, and suggest some possible areas for future research on the emergence of the problem of adolescent pregnancy after World War II. Adolescent Pregnancy Debate in the 95th Congress During the past ten years, the issue of adolescent pregnancy has captured the attention of policymakers as well as the general public. It is virtually impossible today to pick up any newspaper or popular magazine without being reminded of the one million teenagers who become pregnant each year. The Carter Administration made the issue of adolescent pregnancy one of its highest priorities for fiscal year 1979 when it proposed an additional $148 million to deal with this problem—including its new $60 million Adolescent Health, Services, and Pregnancy Prevention Act of 1978.1 While most other health programs languished because of the emphasis on fiscal austerity for fiscal year 1980, the Carter Administration nevertheless called for almost full funding for this proposal.2 Many members of the 95th Congress shared the Carter Administration's concern about the problems associated with adolescent pregnancy. Despite the numerous and obvious weaknesses of the proposed Adolescent Health, Services, and Pregnancy Prevention Act of 1978 and the Carter Administration's overall ineptness in promoting it, a modified version of this bill passed through Congress in the final days of the session under the skillful guidance of Senator Edward M. Kennedy (D-MA) because of a general feeling in both Houses that something had to be done about this new problem.3

24

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

A crucial decision in the development of programs to deal with adolescent pregnancy is how one defines the problem. Therefore it is instructive to consider the different definitions of the adolescent pregnancy problem offered during the debates in the 95th Congress as well as the evidence that was mustered to support each approach. Generally speaking, although policymakers in both the White House and the 95th Congress had ready access to numerous experts on adolescent pregnancy either in the Department of Health, Education, and Welfare (DHEW) or at one of the several congressional hearings, the level and quality of this debate was narrower and more simplistic than one might have hoped or expected.4 Almost everyone in Washington believed that the problem of adolescent pregnancy constituted a very serious social and health crisis that necessitated an immediate response—whether from the federal, state, and local governments or from private citizens and organizations. Both the policymakers and the news media emphasized the "epidemic" nature of adolescent pregnancy. Many members of the Carter Administration and the 95th Congress assumed that Americans faced a new and growing crisis and that drastic steps dealing with this threatening situation had to be initiated at once.5 Throughout the debates on the Adolescent Health, Services, and Pregnancy Prevention Act of 1978, very few of the participants ever asked whether adolescent pregnancy in the 1970s was actually an unprecedented and growing problem for our society. In fact, the high rate of adolescent pregnancy, particularly among younger teenagers, and the large number of pregnant adolescents were repeatedly cited by supporters of the proposed legislation to justify the sense of urgency necessary to pass a bill that many senators and representatives privately admitted was hastily conceived and poorly drafted.6 One can certainly defend the need to deal with the problems associated with adolescent pregnancy in America today. As has been already pointed out, nearly a million teenagers become pregnant each year and almost 500,000 of them have babies. Even more startling is the estimate that 40 percent of all teenage girls will become pregnant as adolescents.7 The well-documented adverse social and health effects of early childbearing for both the

An "Epidemic "of Adolescent Pregnancy ?

25

mother and the child and the exorbitant welfare costs to our society both justify increased efforts in this area.8 But an historical perspective on the problem of adolescent pregnancy offers a somewhat different and more complex picture than the one supplied by the news media and policymakers. Contrary to the general impression of many Americans, the overall rate of teenage childbearing has not increased dramatically.9 In fact, the overall rate of teenage fertility has declined during the past twenty-five years (see Figure 2-1). The rate of teenage childbearing increased sharply after World War II and reached a peak of 97.3 births per 1,000 women ages 15 to 19 in 1957. After 1957 the rate of teenage fertility declined to 52.8 births per 1,000 women ages 15 to 19 in 1977; by 1983 it has leveled off to 51.7 births per 1,000 women ages 15 to 19.10 Thus, although the public concern about teenage childbearing has greatly increased since the late 1950s, the actual rate of adolescent childbearing has decreased by 44.8 percent during the past twenty-five years. If the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 is truly a response to the demographic trends among adolescents, it should have been launched during the Eisenhower rather than the Carter Administration. While the drop in teenage fertility is substantial, it is less than that experienced by older women. For example, though fertility rates for teenagers ages 15 to 19 decreased by 40.7 percent from 1960 to 1977, the fertility rates for women ages 20 to 24 and 25 to 29 declined by 56.3 percent and 43.8 percent respectively. Since then, all three groups have experienced a very small drop in fertility, with women ages 20 to 24 still experiencing the largest decline. The few witnesses at the congressional hearings who acknowledged the overall decline in adolescent fertility rates quickly stressed that the number of births to teenagers remains fairly constant. In 1960 females ages 15 to 19 had 586,966 births while their counterparts in 1977 had 559,154 births—a decrease of only 4.7 percent. The reason for the relative stability in the total number of teenage births from 1960 to 1977 is that the number of female teenagers ages 15 to 19 in the population increased by 58.1 percent during this period. It is also important to observe, however, that the number of children born to teenagers declined by 13.3 percent from 1970 to 1977 and decreased another 12.5 percent from 1977 to 1983. In other words, since 1970 a substantial decrease in the

26

FIGURE 2-1. Birth Rates of U.S. Women Ages 15 to 19, 1920-1983

number of births as well as in the birth rate for females ages 15 to 19 has occurred. But the overall rates of teenage fertility do not reveal the complexities of the present situation. The health and social consequences of teenage childbearing are very different for girls ages eighteen or nineteen and girls in younger age groups. Most of the adverse consequences of teenage childbearing are associated with having children at very early ages rather than at eighteen or nineteen (Hayes, 1987; Norton, 1974). Therefore, we should examine the rates of teenage fertility for different age groups during the past eleven years. The birth rate of women 18 to 19 years of age declined by onethird from 1966 to 1977 (see Figure 2-2). The decline in fertility among the older teenagers was nearly the same as that of women ages 20 to 24 and 25 to 29 during the same period. But, the birth rate of teenage girls ages 15 to 17 declined by only 5.3 percent during those eleven years, while that of girls ages 10 to 14 increased by one-third. From 1977 to 1983, however, the fertility of women ages 18 to 19 declined only 3.5 percent, for women ages 15 to 17 it declined 5.6 percent, and for those ages 10 to 14 it declined 8.3 percent. Although fertility has declined substantially among teenagers in the last fifteen years, almost all of the decline has occurred among

An "Epidemic" of Adolescent Pregnancy?

27

FIGURE 2-2. Birth Rates of U.S. Women Ages 15 to 17 and 18 to 19, 1966-1983

older teenagers. The problem of teenage pregnancy, as many observers have noted, affects younger teenagers most dramatically. In 1966 only 30.9 percent of all teenage births occurred to girls seventeen years old or younger; by 1977 that proportion had increased to 39.5 percent (although the proportion dropped to 36.6 percent by 1983). Thus, part of the increased public alarm about adolescent childbearing results from the fact that despite the greater availability of contraceptives, the rate of childbearing among young teenagers has remained relatively constant. Much of the public concern about adolescent fertility focuses on the plight of very young mothers—particularly because the rate of childbearing among girls ages 10 to 14 increased 22.2 percent between 1966 and 1983. In fact, only this younger age group has experienced an increase in fertility rates during the past two decades. The idea of a twelve- or thirteen-year-old having her own child is so shocking to most Americans that it is frequently evoked to muster support for remedial programs. We need, however, to see this phenomenon of very early childbearing from another perspective. Though the rates of very early teenage childbearing have increased dramatically, the total number of births in this age group remain small. In 1983 girls under fifteen had 9,752 births—or 2.0 percent of all births under twenty. Thus, while pregnancy among

28

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

very young adolescents is a serious problem, it accounts for only a small portion of overall rates of childbearing among teenagers today.11 This historical perspective on adolescent pregnancy does not invalidate the need for dealing with early childbearing. Obviously, teenage pregnancy is a real problem in today's society. But it does raise questions about the sense of urgency and crisis generated by the supporters of the legislation in the Carter Administration and the 95th Congress. If the demographics of adolescent pregnancy were the major determinant of the need for federal policy, the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 should have been introduced twenty years ago. Had congressmen been more aware of the actual trends in adolescent fertility, many of them probably would have been reluctant to pass the Carter Administration's bill—especially because the legislation had not been carefully considered or marked-up by any of the subcommittees or full committees in the House.12 But the supporters of the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 created a sufficient sense of urgency about the "epidemic" of adolescent pregnancy, and the House conferees agreed to the Senate version of the bill, even though many of them still had serious reservations about hastily enacting such important legislation. Because neither the rate nor the number of pregnant adolescents by themselves can account for the increased public concern about early childbearing today, we might explore another possibility— that the real problem of adolescent pregnancy for most Americans is not the number of pregnant teenagers, but the increasing proportion of out-of-wedlock births. While the rate of out-of-wedlock births (number of births per 1,000 unmarried women) dropped sharply for all other age groups between 1960 and 1977, the rate for teenagers increased rapidly. Thus, though the rate of out-ofwedlock births among women ages 20 to 24 and 25 to 29 dropped by 14.4 percent and 38.6 percent respectively from 1960 to 1977, the rate among unmarried girls ages 15 to 19 increased by 64.0 percent. Since 1977 the rate of out-of-wedlock births among unmarried girls ages 15 to 19 rose 18.3 percent while that of their older counterparts ages 20 to 24 and 25 to 29 increased even more rapidly (23.5 percent and 28.5 percent respectively). In actual numbers, out-of-wedlock births to teenagers ages 15 to 19 have more

An "Epidemic" of Adolescent Pregnancy?

29

than doubled from 87,100 in 1960 to 239,700 in 1977, and then increased to 270,076 in 1983. As a result, the proportion of out-ofwedlock births among teenagers increased dramatically. Of all outof-wedlock births in 1977 46.5 percent occurred to teenagers. Recently, as the number of out-of-wedlock births to older women increased more rapidly, the proportion of all out-of-wedlock births to teenagers in 1983 dropped to 35.4 percent. The proportion of out-of-wedlock births to teenagers varies considerably by age. While 90.4 percent of all births to girls under fifteen were out-of-wedlock in 1983, the percentages for girls ages 15 to 17 and 18 to 19 were 67.5 percent and 45.7 percent respectively. Overall, 54.1 percent of all teenage births in 1983 were outof-wedlock. There are also considerable racial differences in the proportion of out-of-wedlock births among teenagers. While four out of ten births to white teenagers were out-of-wedlock in 1983, almost nine out of ten births to nonwhite teenagers were out-of-wedlock. The proportion of these births for both white and nonwhite teenagers have increased sharply since 1960. We can subdivide teenage births into three different categories in order to analyze the trends in out-of-wedlock births in more detail: (1) births conceived in marriage, (2) births conceived outside of marriage but occurring within marriage, and (3) births both conceived and delivered out-of-wedlock. Estimates of changes in these three groups of births from 1950-54 to 1980-81 reveal that the proportion of first births that were conceived out-of-wedlock by teenagers ages 15 to 19 increased from 30.1 percent to 71.6 percent (O'Connell and Rogers, 1984). The proportion actually born out-of-wedlock also increased dramatically because the number of premarital pregnancies legitimized by marriage declined from almost one-half to less than one-third during these years.13 In other words, the great increase in out-of-wedlock births among teenagers is the result of an increase in premarital conceptions and a corresponding decrease in marriages. Increasingly, young people today would rather have a child out-of-wedlock than be forced into an early, unwanted marriage. As the number and the proportion of out-of-wedlock teenage births increases, one might expect a sizable increase in the number of children put up for adoption. In fact, the reverse appears to be

30

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

true—increasingly the mothers of out-of-wedlock children are choosing to keep them. Fifteen years ago, perhaps as many as 50 percent of all out-of-wedlock infants were relinquished for adoption. Today, almost 90 percent of all out-of-wedlock births are kept by the mother.14 As the number of out-of-wedlock births among teenagers increases and the burden of teenage childbearing to society increases because adolescents choose to keep their children rather than place them up for adoption, the American public has become increasingly upset. This concern about the financial cost to society is compounded by the expansion of federal and state welfare programs such as the Aid to Families with Dependent Children (AFDC) over the last twenty years. As a result, the total welfare cost of adolescent pregnancy today is much higher than in the past. Though we do not have comparable figures for the 1950s or 1960s, Kristin Moore of the Urban Institute calculated that the federal government disbursed $4.65 billion dollars through AFDC in 1975 to households containing women who bore their first child while teenagers (U.S. Congress, House, Select Committee on Population, 1978a: 284-304). This represented nearly half (49.7 percent) of the total AFDC expenditures in 1975. Furthermore, the AFDC costs of teenage childbearing greatly underestimate the actual costs to taxpayers because they do not include the cost of other federal programs such as Medicaid, food stamps, or state and local costs. Thus, while the Carter Administration and the 95th Congress had been concerned almost exclusively with the prevention of adolescent childbearing or the care of pregnant teenagers, they did not consider minimizing the costs to society by reducing the proportion of out-of-wedlock births. Most of the debate about adolescent pregnancy centered on the female with very little attention to the male role—particularly in regard to the possible financial responsibility for his child.15 Should greater efforts have been made to force young fathers to support the adolescent mother—thus making it easier for her to raise the child as well as partially reducing the welfare costs to the rest of society? Or, should more effort have been made to encourage the male to marry the expectant young mothers, the traditional solution of the 1950s and 1960s? Because the likelihood of an out-of-wedlock birth is much higher among blacks than whites, even after controlling their socio-economic characteristics, should

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31

more attention have been paid to the factors within black culture that contribute to higher rates of out-of-wedlock births among adolescents? Should adolescent parents be encouraged to relinquish their children for adoption in order to help themselves and to relieve the welfare burden on the rest of our society? Every one of these policy suggestions have possible objections. For example, if a fifteen-year-old girl is about to have a baby, would we really want her to marry an equally young and probably immature teenage male—thus handicapping both their future education and careers? Some fragmentary evidence suggests that the males in these situations are usually older than the females and may be capable of financially and emotionally helping the family (Williams, 1977). Critics point out that these early marriages are much more likely to end in divorce or separation than later ones—thus negating any possible advantages of an early marriage (Weeks, 1976). Yet a recent study (McLaughlin, Grady, Billy, Landale and Winges, 1986) shows that three-fourths of white teenage marriages to legitimize a premarital conception before birth are still intact after ten years as are about one-half of similar black teenage marriages. Could the problem of marital dissolution among teenagers be minimized further if the government developed specific programs to help young couples stay together and to permit both of them to continue their education? The basic question remains; is the presence of a father an asset or a liability in terms of the needs of the children, the young parents, and the rest of society? I am not necessarily advocating any of these particular policies as a desirable solution to the problems associated with the increase of out-of-wedlock births among adolescents today—especially as we have so little information on the likely effects of such actions. Yet each of these issues should have been carefully considered and debated by the policymakers in Washington as possible alternatives or supplements to the Carter Administration proposals. The fact that they were not even mentioned by most Administration spokespeople or congressmen clearly implies that the framework for the entire debate on adolescent pregnancy was too narrow and ahistorical. By not considering the changes in adolescent pregnancy and childbearing over time, the Carter Administration and the 95th Congress failed to address directly issues such as the increase in out-of-wedlock births.

32

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

It was no accident that the consideration of alternative policies by the Carter Administration and the 95th Congress did not focus on possible solutions to the increase in the number and the proportion of out-of-wedlock births. Motivated mainly by humanitarian consideration, the advocates of the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 wanted to help these young girls and their children. They were not particularly concerned about the welfare costs associated with adolescent pregnancies, except as a rationale for urging more federal spending to prevent initial unintended pregnancies. Supporters of increased federal funds for pregnant teens did not want to raise the issue of the financial responsibility of the young father, because they feared that it might suggest or encourage more punitive legislation against teenagers.16 As a result, the most knowledgable and active individuals and organizations on the issue of adolescent pregnancy, who might have raised the policy implications of the rise in out-ofwedlock births, chose to minimize this issue and to emphasize the needs of young adolescent mothers and their children. The success of these advocates is all the more impressive when we remember that this entire matter was debated immediately after the success of the "tax-payers' revolt" in California with the passage of the Jarvis Amendment.17 Another example of how the consideration of alternative policies might have benefited from an historical perspective is the debate between those who wanted to use the additional funds to prevent initial unintended pregnancies and those who proposed using them for aiding pregnant teenagers. In fact, the major debate in the 95th Congress was not over the nature or extent of adolescent pregnancy, but over the way in which these additional funds should be apportioned. Most observers stressed the need for preventing unintended pregnancies. Thus, Julius Richmond, Assistant Secretary for Health of DHEW, noted in his testimony before the House Select Committee on Education: Prevention is our first and most basic line of defense against unintended adolescent pregnancies. The Department's prevention strategy takes several forms, including education on the responsibilities of sexuality and parenting, family planning services, and large increases in research directed at prevention.

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We anticipate that a significant proportion of the $60 million budgeted for our proposed program will go to projects providing such family planning and educational services (U.S. Congress, House, Committee on Education and Labor, 1978: 18).18

The Senate Committee on Human Resources, at the urging of Senator Kennedy, disagreed with the Administration's emphasis on prevention in this bill and rewrote it to emphasize almost exclusively the use of the $60 million for helping pregnant teenagers. The committee reasoned that enough money had already been allocated for family planning programs under Title X of the Public Health Services Act.19 Furthermore, the committee was persuaded by some of the witnesses who argued that many of the pregnant adolescents really wanted to have children; thus, further investments in family planning programs for adolescents would have little impact. As James F. Jeckel, Associate Professor of Public Health at Yale University, testified: As Congress considers this bill, I know there are a number of questions that have been troubling Members of Congress. One is the practical question, "Wouldn't it be better to prevent the problem in the first place, rather than to wait for it to occur and then try to help out?" My response is that it certainly would be better to prevent truly unwanted children, and that to the extent that they are being produced, this issue should be forcefully addressed. However, I cannot agree with a further conclusion that the bill before us, therefore, should be only a prevention-oriented bill. This aspect is important, but it is already being addressed to some extent through other Federal programs, and even if all of the clearly unwanted pregnancies were prevented, there would still be several hundred thousand children born each year to teenagers. There is abundant evidence that we cannot eliminate all, or most, of the teenage pregnancies, so that we must face up to how to deal with those that will continue to occur for the foreseeable future (U.S. Congress, House, Committee on Education and Labor, 1978: 33).20

Jeckel's argument that further prevention of adolescent pregnancies would be very difficult, if not impossible, is not widely shared by researchers or practitioners in this field. But a series of witnesses, coordinated by the Joseph P. Kennedy, Jr., Foundation

34

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

under the guidance of Eunice Shriver and Robert Montague, left many of the congressmen with the mistaken impression that family planning programs are relatively ineffective in reducing adolescent pregnancies.21 Most of these experts did not even consider the fact that while the pregnancy rate of young adolescents declined only slightly during the past fifteen years, without the increased use of contraceptives it would have risen rapidly as a consequence of the dramatic increase in teenage sexual activity. To appreciate fully the success of primary prevention among these young adolescents, we need to take into consideration changes in their sexual activity as well as in their use of contraceptives. Evidence from a variety of sources indicates a rise in the level of sexual activity among teenagers during the 1960s and 1970s and then a slight decline during the early 1980s.22 Though some of the studies of sexual activity are based on small sample sizes and unrepresentative populations, the national surveys of sexual and contraceptive practices among female adolescents in 1971, 1976, and 1979 by Melvin Zelnik and John Kantner convincingly document an increase in the level of sexual activity among unmarried female adolescents (1977, 1978a, 1978b, 1980). The most recent national survey of adolescent sexual behavior shows a small overall decline from 1979 to 1982 (Moore, Wenk, and Hofferth, forthcoming). In 1971 approximately 27.6 percent of unmarried females ages 15 to 19 living in metropolitan areas had experienced intercourse. By 1976 that percentage had risen to 39.2 percent and peaked in 1979 at 46.0 percent. The percentage of unmarried females ages 15 to 19 living in metropolitan areas who were sexually active dropped to 42.2 percent in 1982. The increase in sexual activity among unmarried females occurred for every age group and was particularly pronounced among seventeen-year-olds. By age nineteen, 69.0 percent of all unmarried females living in metropolitan areas in 1979 had sexual intercourse compared to 46.4 percent for their counterparts in 1971 and 59.5 percent in 1976. In 1982 the figure returned almost to the 1976 level with 56.9 percent of unmarried females age nineteen living in metropolitan areas having experienced sexual intercourse. Unmarried black female adolescents were more likely to have engaged in intercourse than their white counterparts. Among all unmarried black women ages 15 to 19 in 1982, 57.8 percent have

An "Epidemic" of Adolescent Pregnancy?

35

experienced sexual intercourse compared to 40.2 percent of unmarried white women ages 15 to 19 (Pratt, Mosher, Bachrach and Horn, 1984). Differences between white and black adolescent girls diminished as white girls significantly increased their sexual activity from 1971 to 1979 and only slightly decreased it during the next three years; on the other hand, the level of sexual activity among black girls increased at a slower rate from 1971 to 1979 and decreased more from 1979 to 1982. Though the level of sexual activity among female teenagers rose dramatically between 1971 and 1982, the frequency of intercourse among sexually active teenagers remained low. In the month preceding the Kantner and Zelnik survey in 1979, nearly half of all sexually experienced unmarried women ages 15 to 19 abstained from any intercourse, while another quarter had engaged in sexual intercourse only once or twice during that month (Zelnik and Shah, 1983). While sexual activity has increased alarmingly among adolescent girls, there has also been an encouraging increase in the use of contraceptives. Among unmarried girls ages 15 to 19 in 1971, 45.4 percent used contraception the last time they had intercourse. By 1976 the percentage of unmarried girls ages 15 to 19 who used contraception at the time of their last intercourse has risen to 63.5 percent. Contrary to the testimony offered by several witnesses before the 95th Congress, adolescents were much more willing to use contraceptives in 1976 than their counterparts five years earlier. Since 1976 contraceptive use among sexually active teenagers has continued to increase (Hayes, 1987). A major change has occurred since 1971 in contraceptive practice among teenagers. Not only are an increasing number of sexually active adolescents using some form of contraception, but they are also more apt to use the pill. In 1971 only 15.1 percent of the unmarried girls ages 15 to 19 used the pill at the time of their last intercourse, but 31.2 percent of their counterparts in 1976 used the pill.23 Unfortunately, many sexually active teenagers continue to use contraceptives irregularly and often rely on such unreliable practices as withdrawal despite the recent overall improvements in adolescent use of birth control. In other words, the rate of pregnancy among young adolescents has remained almost constant despite the increase in sexual activity

36

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

because an increasing proportion of sexually active adolescents use contraceptives. Furthermore, teenagers have been more willing and able to use family planning clinics in the 1970s. Adolescents using family planning clinics rose from 396,000 in 1971 to 1,150,000 in 1976.24 In 1983 about 1,568,000 adolescents visited family planning clinics (Torres and Forrest, 1985). Whereas witnesses such as Sargent Shriver and Dr. James Jeckel emphasized the unwillingness of young teenagers to use contraceptives, the recent record of adolescent behavior suggests the opposite. Though it will be impossible, of course, to eliminate all initial unintended pregnancies, it seems that some reduction in the current level of adolescent childbearing would be possible if sufficient funds and improved programs made contraceptives available to teenagers.25 These are only a few of the problems associated with the Adolescent Health, Services, and Pregnancy Prevention Act of 1978, but they illustrate my contention that the debate was unnecessarily narrow and ahistorical. It is only fair to point out, however, that the consideration of this bill probably was as thorough as that of most other pressing social legislation in recent years. Like many legislative acts, the final passage of the modified bill had as much to do with the politics of the Carter Administration and the 95th Congress as with the actual needs of adolescents. In view of the disorganization of the Adolescent Pregnancy Initiative within DHEW and the speed with which Congress acted, perhaps it is surprising that the debates and discussions were informed and thorough at all. Nevertheless, the deliberations about adolescent pregnancy in the 95th Congress were too limited and time bound. By failing to see the issue from a broader, long-term perspective, the general public and many policymakers within the Carter Administration and the 95th Congress thought that their legislation had addressed the problem of adolescent pregnancy. In reality, it only provided very limited services for a small percentage of pregnant teenagers. As Frank Furstenberg so angrily and eloquently testified before the House Select Committee on Population: One is compelled to ask, then, why HEW is designing a program that is destined to have, at best, a token impact? How will they deal with the resentment created when Government reneges on its prom-

An "Epidemic" of Adolescent Pregnancy?

37

ise to help teenage parents and their families? Will this program be yet another instance of Government playing musical chairs with social maladies? (U.S. Congress, House, Select Committee on Population, 1978a: 168)

An historical approach to the problem of adolescent pregnacy probably would not have alleviated the difficulty of trying to deal with early childbearing with very limited funds. It might, however, have provided a more realistic framework in which to evaluate the needs of teenagers and to assess the likelihood of success of various programs. A few participants were aware of the actual trends in adolescent pregnancy and their implications for federal policies, but most witnesses and almost all of the decision makers simply accepted the myth of an "epidemic" of adolescent pregnancy as a growing and unprecedented problem that necessitated immediate action. The legislation that was passed certainly benefited some pregnant teenagers and in some ways was long overdue, but the manner in which it was sold to the Congress and to the public generated considerable anger and frustration when people finally realized exactly what had been enacted. Furthermore, it soon became apparent that the 96th and subsequent Congresses were reluctant to provide more funding for any social programs, including family planning services for adolescents. Thus, the rewriting of the Carter Administration's Adolescent Health, Services, and Pregnancy Prevention Act of 1978 to provide funding almost exclusively for pregnant teenagers proved to be an unwise reallocation of scarce resources at a time when inflation was undercutting existing family planning programs.26 Research Opportunities and Needs from a Twentieth-Century Historical Perspective If policymakers lacked an historical perspective on adolescent pregnancy, the same can be said about most other scholars working in this area. Though one might have expected that at least some historians would have provided us with a broader, long-term analysis of this issue, few historians have studied adolescent pregnancy

38

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

in the twentieth century. As a result, any efforts to explore fully the research possibilities of adolescent pregnancy from an historical perspective would require a book-length manuscript by itself, because the field is basically untapped. Therefore, I will only mention a few of the many research possibilities in order to illustrate the potential in this area, rather than attempting a comprehensive evaluation of the entire field. One obvious research question that arises from the earlier discussion of the Adolescent Health, Services, and Pregnancy Prevention Act in the 95th Congress is why that bill passed in 1978 rather than earlier when the rate of adolescent pregnancy and childbearing was much higher. Several considerations immediately come to mind. For example, the federal government and most states were unwilling to finance contraceptive services even for adults until the late 1960s.27 Once the first public supported family planning programs were developed, they often deliberately did not provide services for minors. Policymakers considered programs for adolescents a highly controversial and politically dangerous issue. Even today, the provision of contraceptives for unemancipated minors without parental notification remains a very sensitive political issue in Washington.28 Another factor that may have impeded the development of federal programs for adolescents in the 1950s and 1960s was that contraceptive technology was not as highly developed then as in the 1970s. Prior to 1960, the vast majority of women in the United States experienced at least one unplanned pregnancy during their reproductive years. Only one-quarter of all women went through these years without one or more "accidental" pregnancy—and one-third of all women gave birth to a child after the intended completion of the family (U.S. Congress, House, Select Committee on Population, 1978b). With the introduction of oral contraceptives, IUDs, and voluntary sterilization, the likelihood of an unplanned pregnancy has greatly diminished for most women (Westoff and Ryder, 1977). In fact, the problem of adolescent pregnancy seems as anomalous as it does because adolescent girls still continue to have large numbers of unintended pregnancies while older women have managed to eliminate most of their unintended pregnancies.29 In the 1950s and 1960s the immediate financial cost of adolescent

An "Epidemic" of Adolescent Pregnancy?

39

childbearing was less burdensome to the rest of society. Not only has the percentage of out-of-wedlock births among teenagers skyrocketed, but the amount of state and federal support for young unwed mothers and their children has also increased.30 In the 1970s and early 1980s most Americans experienced little, if any, growth in real income so they are increasingly reluctant to support a seemingly large welfare program.31 Perhaps the direct and indirect costs of early childbearing, particularly for the mother, also increased over time. As the proportion of young people completing high school has risen and as the pressure to do so has intensified, the negative aspects associated with dropping out of school are more evident.32 At the same time, our expectations of the possible roles for women within society are changing. Whereas in the 1950s most Americans simply assumed that mothers of young children would remain at home, in 1976 37.4 percent of married women living with husbands who had children under six years old were in the labor force (Wattenberg, 1978). With the increased likelihood of married women entering the labor force, considerable research is underway to ascertain the short-term and long-term costs of adolescent childbearing for the mother, her child, and society. The preliminary results of these investigations have documented the high costs to both society and the individual adolescent.33 The passage of the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 also needs to be considered within the context of the abortion debate. In many ways, the controversy over abortion in the Carter Administration and the 95th Congress made it advantageous for policymakers to try to prevent initial unintended pregnancies or help pregnant adolescents keep their children rather than seek an abortion.34 In fact, the early efforts within the Carter Administration to develop a program for adolescent pregnancy was explicitly seen as part of their "alternatives to abortion" program (Rosoff, 1978). Therefore, when many of the "pro-choice" and "pro-life" forces united behind the Adolescent Health, Services, and Pregnancy Prevention Bill, congressmen found the bill attractive; it permitted them to support positive legislation that seemed to have widespread support and was relatively inexpensive in this highly controversial area.35 Some might

40

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

even argue that the bill would not have been enacted if abortion had not become such a seemingly important political issue in Washington and among the electorate.36 Finally, one should also examine the role of the various interest groups in this area. Although still unacknowledged by most scholars and the news media, it seems apparent that a few organizations and individuals exerted a very powerful influence on the recent course of events. For example, Planned Parenthood—through its closely affiliated yet independent research and lobbying arm, the Alan Guttmacher Institute—played a major role in convincing the public and our officials of today's "epidemic" of adolescent pregnancy. The Institute's pamphlet 11 Million Teenagers: What Can Be Done About the Epidemic of Adolescent Pregnancies in the United States (Alan Guttmacher Institute, 1976) is one of the most influential publications in this field. Though the overall presentation of the data is misleading, very few scholars and almost no one in the news media has challenged it.37 Instead, this well-written booklet provided the framework, though often unacknowledged, for most news stories and the briefing papers prepared for decision makers in the Carter Administration and the 95th Congress.38 Similarly, though with a different perspective than that of Planned Parenthood, the efforts of Eunice Shriver and the Joseph P. Kennedy, Jr., Foundation were very influential, if not absolutely essential in the final passage of the bill.39 Thus, any evaluation of the enactment of the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 will need to consider not only the general trends in adolescent pregnancy and the social and political mood of the country, but also the activities of specific groups and individuals on its behalf. This may pose an analytical problem, however, because social historians in particular have sometimes been rather naive and simplistic in analyzing the role of interest groups in facilitating legislation or in influencing public opinion.40 Besides considering the factors that have led to the enactment of the Adolescent Health, Services, and Prevention Act of 1978, historians should also consider more general areas of research on adolescent pregnancy. Though I cannot review the entire field in a few paragraphs, some observations about the studies available to policymakers in the late 1970s will provide perspectives on the research opportunities and problems in this area.

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41

The quality of social science research on adolescent pregnancies varies considerably. Some of the studies, particularly those funded by the Center for Population Research of the National Institute for Child Health and Human Development, are very well done— employing good research designs as well as relatively sophisticated statistical techniques such as path analysis and multiple classification analysis (e.g., Moore and Caldwell, 1976). Most of these studies focused on the adverse social and economic effects of early childbearing on the young mother, though the Center for Population Research is now turning to other issues as well. Many of the other studies, however, are poorly designed and rely on crude and limited statistical techniques. This is particularly true of those commissioned by some of the other agencies within DHEW, which were often used for policy purposes.41 Furthermore, the weakest aspects of research on adolescent pregnancy tend to be those dealing with the sexual activity of teenagers—though there are a few notable exceptions such as the analyses by Melvin Zelnik and John Kantner (1977, 1978a, 1978b, 1980).42 Two major weaknesses seem to characterize most of these earlier efforts: the relative scarcity of policy-oriented studies and the lack of a life course perspective toward adolescent pregnancy. Most investigations of adolescent pregnancy analyze basic issues such as the relationship between early childbearing and the future earnings of the mother. Very little effort has been made to ascertain the policy implications of adolescent pregnancy for society or the federal government. The few studies on such issues, such as Kristin Moore's (1978) analysis of the AFDC costs of early childbearing, were being done at the direct instigation of the 95th Congress rather than of the Carter Administration. There are several reasons for the lack of policy-oriented analyses of adolescent pregnancy. Most scholars tend to avoid policy-oriented issues, preferring instead to examine more basic relationships at the individual or family level. In addition, the federal bureaucracy and the 95th Congress did not insist on such studies because many administrators and politicians remain rather skeptical of the real value of social science research.43 Finally, the agencies in DHEW during the Carter Administration charged with most of the responsibility for analyzing the effectiveness of family planning programs, such as the Office of Family Planning, usually lacked the trained person-

42

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY?

nel capable of directing such studies and sufficient interest to commission such analyses.44 As a result, though the Carter Administration and the 95th Congress seemed committed to a major effort in the area of adolescent pregnancy, those service programs were developed without any real guidance from social science research on the relative effectiveness of different approaches. As we shall see in the next chapter, the Reagan Administration and the 96th Congress showed more interest in policy-oriented research with the enactment of the Adolescent Family Life Bill in 1981. The other major shortcoming of most of the early studies is that they are very narrowly focused on the interaction between the individual and some outcome, such as future earnings, and fail to take into consideration other factors such as the role of the family or likely developments in the economy. For example, it is amazing and depressing how little we know about the role of the family, the school, the peer group, and the rest of society in the decision of adolescents to become sexually active.45 Perhaps we should employ a life course approach, as advocated by scholars such as Glen Elder, to analyze adolescent pregnancy. A life course framework would relate the personal development of the adolescent to the social definitions of those changes and to broader shifts in society as a whole, and may provide us with a better understanding of the process of change in the lives of adolescents today.46 If we are to comprehend the factors that have altered the pattern of behavior of adolescents in regard to sexual activity or early childbearing, we need to consider changes over time as well as among different social groups. The almost universal ahistorical nature of most studies of adolescent pregnancy, in large part a function of their heavy reliance on cross-sectional data, seriously limits their ability to provide information for policymakers about the interaction of individual and societal factors in producing changes.47 A life course perspective is also needed to incorporate biological development. Various kinds of behavior are commonly identified with different stages of child development. Recently, more emphasis is being placed on environmental factors at the expense of "natural" maturation.48 What is needed is an attempt to integrate these approaches from a life course perspective. For example, Edward Adelson's study of adolescent ideology argues that chil-

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dren's understanding of cause and effect relationships are narrow and concrete. As the child goes through adolescence, his cognitive capabilities develop so that: He is more able to transcend the sheer particularity of an act, to place behavior within a web of circumstances . . . by expanding and commanding time, linking past to present and present to future; the act has a history and its effects extend forward in time. . . . The young adolescent is locked into the present. His view of the future is constricted: he may grasp the effect of today on tomorrow, but not on the day after tomorrow (cited in Chilman, 1979: 48).

Hence, it is not surprising that young adolescents, male or female, may be unable to grasp the future significance of early childbearing either on their own lives or that of their offspring. Furthermore, Adelson contends that younger adolescents rarely reason in cost/ benefit terms in evaluating some course of action. Instead, they are apt to make an arbitrary choice based on impulse rather than a consideration of the future (Chilman, 1979). Programs designed to reach younger adolescents, therefore, may need to be structured differently from those intended for their older counterparts. Similarly, a life course perspective would encourage a researcher to consider variations in the development pattern of adolescents due to the different historical periods in which they grew up. Catherine Chilman has provided a very interesting statement on how the development of adolescents in the 1960s may have differed from those in the 1970s: It is interesting to realize that the 16-year-olds of 1976 were born in 1960. Their development years were probably quite different from those of young people who reached this age in 1966. The latter were likely to have experienced a childhood of considerable security and conventionality, but as teenagers they may have been caught up in the social movements of the 1960s and experienced the disintegration of these movements. They probably had to struggle with parents and other adults to win their personal freedoms in the new mode; for them, "alternative lifestyles" may have been an exciting discovery and a symbol of their growing autonomy. In contrast, the 16-year-olds of 1976 grew up as children in chaotic, confusing times. They probably became individually aware of

44

AN "EPIDEMIC" OF ADOLESCENT PREGNANCY? the larger society in the early 1970s, a time of widespread disillusionment with Government, business, and industry. It is unlikely that they have needed to fight much with their parents for personal freedoms because there has been a large shift in the attitudes of adults as well as youth. Because adolescents need to search for their personal identities and values and separate themselves from their parents, will their search take them in more conservative, traditional directions or on to new explorations of individual self-expression as young men and women (Chilman, 1979: 90)?49

Most of my discussion of research opportunities and needs has been focused on the post-World War II era. In part, this reflects the fact that adolescent pregnancy, as a perceived social problem, is largely a contemporary phenomenon that has stimulated analysis only recently. Yet the issue of adolescent childbearing deserves and requires an even longer time perspective than the past twenty or thirty years. Furthermore, I suspect that when more historians do begin to examine this issue, they will focus on the late nineteenth and early twentieth century simply because of the tendency of most social historians to analyze these periods, rather than the post-World War II era. The first thing that needs to be established is whether the level of adolescent childbearing was as high in the past as it is today. The data from the 1920s indicates that early childbearing was as prevalent then as it is today (see Figure 2-1). As we have seen in the previous chapter, the scattered bits of evidence we have suggest that adolescent childbearing was not as widespread in the late nineteenth century. For example, while the number of children born per 1,000 women ages 15 to 19 in the United States was 69 in 1910, and 61 in 1940, it was only 18 in 1885 for women ages 14 to 19 in Massachusetts (U.S. Bureau of Census, 1971: 356-398). Similarly, in two studies of marital fertility in Boston and five Essex County (Massachusetts) communities in 1880, the rate of childbearing and marriage among women under twenty years old was so low that the standardizd rates for women were constructed only for those ages 20 to 49 (Hareven and Vinovskis, 1975, 1978). Although the question of adolescent childbearing has not received much attention from historians, out-of-wedlock births have. A recent collection of comparative studies of bastardy in Western

An "Epidemic" of Adolescent Pregnancy?

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Europe and North America has documented the prevalence of high rates of out-of-wedlock births in the late sixteenth century, the late eighteenth and early nineteenth century, and today (Laslett, Oosterveen, and Smith, 1980). While little effort is made to analyze any possible relationship between adolescent pregnancy and out-of-wedlock births, these essays are suggestive for areas of future research. For example, one of the most interesting finding in these studies is the importance and persistence of regional differences in illegitimacy. Despite the great changes in the levels of illegitimacy over time, the regional differences persist—leading to the suggestion that a "bastardy-prone sub-society" may exist. According to this concept, "bastardy-producing" women, living in the same area and often related to each other, pass on such values and practices to their children and thus perpetuate this sub-society. This question of whether groups exist within society who deviate from established norms and pass on their values and behavior to their children has attracted much attention from the American public. During the 1960s and early 1970s the "culture of poverty" argument gained considerable popularity. According to this perspective individuals would find it virtually impossible to escape from their impoverished upbringing and environment. Today, this concept is being reapplied to the problem of adolescent pregnancy. Many congressmen, for example, accept the idea that the children of today's teenagers will themselves become adolescent mothers unless federal or state funded programs intervene to break this cycle of early childbearing. Despite the popularity of the concept of a subculture of poverty or adolescent childbearing, little empirical validation of this important issue exists. While several authors suggest the existence of a "bastardy-prone sub-society" in the past, others reject the validity or even the usefulness of this construct (Laslett, Oosterveen, and Smith, 1980). Similarly, though many people are talking of a culture of adolescent childbearing that persists over time, the documentation and analysis is yet to be done. These are only a few of the many interesting and useful issues that might be considered by historians analyzing adolescent pregnancy in the twentieth century. Because so little has been done to date, the field must be charted and explored before we can prop-

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erly evaluate its importance for understanding our past society as well as for providing an historial perspective on contemporary concerns. In fact, we as social scientists will have to be extremely careful that our views of the problem today do not distort our interpretations of that phenomenon in the past. Whether anything we find about adolescent pregnancy in the more distant past will fundamentally alter our approach to the problem today remains to be seen. In any case, the effort to analyze this issue needs to be made in and of itself because it may provide us with another important and hitherto unexplored aspect of adolescence in the past.50

3 The Origins and Development of the Office of Adolescent Pregnancy Programs

In chapter two we explored the reactions of the Carter Administration and the 95th Congress to the so-called "epidemic" of adolescent pregnancy in the 1970s by analyzing how policymakers and expert witnesses defined the problem in the debates over the Adolescent Health, Services, and Pregnancy Prevention Act of 1978. Now we will consider the problem of adolescent pregnancy by tracing the origins and changes in the Office of Adolescent Pregnancy Programs (OAPP). In trying to understand the way our society defines and copes with social issues such as adolescent pregnancy, it is often useful to trace the creation and development of a government agency specifically designed to deal with that problem. The debates over the establishment of that agency and its subsequent activities provide clues as to how policymakers formulate responses to a perceived problem, and also reveal how outside groups try to influence legislative and administrative decisions. The issues of adolescent sexuality, pregnancy, and childbearing received intensive public and legislative attention during the 1970s and 1980s. In this chapter we will examine some of the major controversies surrounding these topics by analyzing the unsuccessful effort to pass the "School-Age Mother and Child Health Care Act" of 1975 and the successful enactment of the Adolescent Pregnancy Program in the Department of Health, Education, and Wel47

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fare (DHEW) in 1978 by the 95th Congress, which led to the establishment of the Office of Adolescent Pregnancy Programs (OAPP). We will then consider the activities of OAPP during the Carter Administration. Finally, we will examine the transformation of that program into the "Adolescent Family Life Program" in 1981 by the 97th Congress. Though at first glance the two programs may seem to be nearly identical, many of the activities and responsibilities of the programs have been modified to reflect the recent changes in federal efforts to deal with the problems of adolescent pregnancy.

Earlier Efforts to Deal with Adolescent Pregnancy Though adolescent pregnancy and childbearing increased dramatically after World War II, little effort to deal with these developments took place at the federal, state, or local levels. Because most adolescent childbearing during the 1950s occurred within the context of an early, though often unanticipated marriage, few Americans were particularly disturbed by their occurrence. Teenage girls who became pregnant and did not marry the father usually dropped out of school and frequently placed the child up for adoption (Weeks, 1976). Thus, though the problems for the young mother and her child in the 1950s may have been as complex and as serious as today, most federal, state, and local authorities did not take upon themselves the responsibility for either preventing these pregnancies or helping the young family. During the 1960s and 1970s, fundamental changes took place in the general role of the federal government in dealing with social problems and in public attitudes toward adolescent childbearing. This created a more favorable climate for programs designed to prevent adolescent pregnancies or to help pregnant teenagers.1 As part of the "Great Society" program initiated by President Lyndon Johnson and expanded by his successor, President Richard Nixon, the federal government sought to eliminate domestic poverty through special programs such as the Public Health Title X Family Planning Services Program designed for low income women (Little-

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wood, 1977). These early federal efforts at prevention did not explicitly focus on teenagers' need for contraceptive services, but adolescents accounted for more than one-fourth of the patients going to those family planning clinics in the early 1970s (Torres and Forrest, 1983; U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 332). By the mid-1970s the contraceptive needs of sexually active adolescents started receiving more attention because their unintended fertility rates remained much higher than those among older women. During the late 1960s and 1970s, some pregnant teenagers became eligible for assistance from federal programs created to assist the poor such as Medicaid (Title XIX), Maternal and Infant Care and Youth projects (Title V), and Early Periodic Screening, Diagnosis, and Treatment (EPSDT) (U.S., Congress, Senate, Committee on Labor and Public Welfare, 1975: 336-359). However, most of these programs were not designed specifically to meet the needs of pregnant adolescents and thus were lacking a well-coordinated delivery of services. From the perspective of the future orientation of the Office of Adolescent Pregnancy Programs (OAPP), an important precedent was set in 1963 when the Children's Bureau funded a demonstration-evaluation special school for pregnant girls at the Webster School in Washington, D.C. At that time most public school systems barred pregnant girls from attending regular classes. The Webster School experiment assumed that pregnant teenagers needed comprehensive educational, health, and counseling services in order to overcome the disadvantages associated with early childbearing (Klerman and Jeckel, 1973). The Children's Bureau continued its support of the comprehensive model of service delivery by funding similar programs in New Haven, Hartford, and Baltimore. Outside organizations such as the National Alliance Concerned with School-Age Parents (NACSAP) and the Consortium on Early Childbearing and Childrearing (CECC) (formerly the Cyesis Program Consortium) then used the success of these demonstration-evaluation models to argue for more federally funded comprehensive service centers for pregnant adolescents (Klerman and Jeckel, 1973).2 The federal government directly funded only a few comprehensive service programs for pregnant teenagers; local communities

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supported many others. In 1976 NACSAP listed a total of 1,132 programs offering services to sexually active adolescents and teenage parents in its directory of service providers—although only fiftyfour of them (4.8 percent) were considered to be truly comprehensive (offering medical care, family planning services, alternative schooling, counseling, and/or social services). Maternity homes made up the bulk of the existing programs (77.8 percent) and were either educationally or medically based (JRB, 1981). By the early 1970s, many of the advocates of services for pregnant teenagers were convinced that comprehensive services, preferably available at a single site, were effective and that additional federal funds were necessary for a major expansion of the current system. As a result, Senators Edward M. Kennedy (D-MA) and Birch Bayh (D-IN) proposed the "School-Age Mother and Child Health Care Act" (S. 2358) of 1975 to "encourage coordination and improvement of existing services, as well as the provision of new services where necessary" (U.S., Congress, Senate, Committee on Labor and Public Welfare, 1975: 5). The "School-Age Mother and Child Health Care Act" was introduced very late in the session (September 1975) and was not expected to pass. The Ford Administration's earlier opposition to the "Child and Family Services Act" of 1975 made it unlikely that the executive office would support this legislation (McCathren, 1981). In fact, though hearings were held before the Subcommittee on Health of the Senate Committee on Labor and Public Welfare, the bill did not reach the floor in either chamber. Yet even this legislation is worth considering in some detail because it provided the substantive basis for the "Adolescent Health, Services, and Pregnancy Prevention Act" of 1978. In addition, the same coalition of groups and individuals who supported the "School-Age Mother and Child Health Care Act" of 1975 would become the primary proponents of the legislation enacted three years later—including the first two directors of the Office of Adolescent Pregnancy Programs (OAPP).3 The "School-Age Mother and Child Health Care Act" of 1975 (S. 2538) was modelled on the Delaware Adolescent Program, Inc. (DAPI)—the only state-wide comprehensive service program for pregnant adolescents (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 469). Like DAPI, the Kennedy bill

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called for the designation of a state agency responsible for this undertaking, the creation of a state plan for comprehensive services, and the establishment of a state advisory council. The decision to channel the federal funds through a state agency may have been an attempt to appease the Ford Administration, which had opposed the "Child and Family Services Act" of 1975 in part because it by-passed the states and provided money directly to local grantees. After several witnesses, including Senator Bayh and Jack Vaughn of the Planned Parenthood Federation of America, questioned the wisdom of designating only state agencies as eligible for receiving the federal funds, Senator Kennedy agreed to reexamine the proposed channeling of funds solely through state agencies (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 558). In future versions of this legislation, the exclusive reliance upon state agencies was dropped.4 The central substantive assumptions behind the "School-Age Mother and Child Health Care Act" of 1975 were that the provision of comprehensive services would significantly improve the lives of the young mothers and their children and that these services had to be integrated. Indeed, the legislation mandated a set of core services to be provided by each project (additional ones could be added as needed). Almost everyone agreed upon the short-term benefits of providing such services, but some individuals questioned the long-term effectiveness of such a program.5 While several studies (Jeckel et al., 1973, 1975; Currie et al., 1972) cited did show the positive impact of special services for pregnant teenagers, none demonstrated the particular efficacy of the set of required core services mandated by this legislation. Finally, though most witnesses agreed on the importance of providing comprehensive services for pregnant adolescents, several participants (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 556, 655) raised questions about the high cost compared to the cost of preventative strategies. One of the major achievements of the DAPI program, according to its director Lulu Mae Nix, was its ability to maximize the effectiveness of existing health, social, and educational services by integrating them both at a state-wide and a local level (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 472–479). The Kennedy initiative valued this accomplishment and targeted

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federal funds for integrating existing services. The legislation assumed that most of the necessary services for pregnant teenagers already existed in local communities and that the major barrier for adolescents was the fact that services were scattered among different providers. The integration of fragmented services would become a hallmark of the Kennedy-Shriver approach to the provision of comprehensive services for adolescents, but was based more on common sense reasoning than on any empirical studies that demonstrated the importance of integrating such services. Several other items appeared in the 1975 legislation that would continue to play an important role in future legislation over the next ten years. For instance, the "School-Age Mother and Child Health Act" required funds for adoption and foster care services as well as for family planning and counseling services. Several witnesses wanted explicit assurance that abortion counseling would also be provided by the legislation, but the bill did not address that issue. It did, however, imply the need for confidentiality in the delivery of these services—a point endorsed by Ford Administration witnesses who testified against state regulations that prohibited adolescents from receiving services without parental consent or involvement (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 32, 334). One of the fundamental weaknesses of this legislation, as several witnesses mentioned (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 381, 445, 471, 554), was the lack of attention paid to the need for further research and evaluation. Whereas the Children's Bureau designed the early comprehensive programs specifically as demonstration and evaluation models, the Kennedy legislation only spoke of a "total evaluation of individual needs" (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 13). The implicit assumption of this initiative, contradicted by the testimony of several of the witnesses, was that enough was already known about comprehensive service centers for teenagers to launch the national $30 million program. Yet another problem with the legislation was that it did not specify in which federal agency it should be placed. Because the legislation was intended to provide comprehensive health, social, and educational services for pregnant teenagers, no single federal agency emerged as the logical home for the new program. The

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Kennedy bill proposed that a unit be established within the Maternal and Child Health Service of DHEW—thus seemingly emphasizing the health aspects of this initiative.6 Though the "School-Age Mother and Child Health Act" basically extended earlier efforts to help pregnant teenagers, many of its advocates also hoped it would provide alternatives to abortion. In fact, Senator Bayh's version of this legislation was even called the "Life Support Centers Act" (S. 2360) and several witnesses explicitly supported these efforts as a way of reducing the number of abortions (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 332, 360, 497-506, 550-551). The close connection of this legislation with the abortion issue provided a preview of the way this initiative would be perceived and packaged during the Carter Administration. The Ford Administration witnesses agreed on the need for reducing adolescent pregnancies and helping pregnant teenagers, but they did not endorse either the Kennedy or the Bayh bills. The administration has committed itself to financing these health services through Medicaid and social service programs on a needs basis. These bills would provide additional narrow categorical programs that already address the problem of teenage pregnancy; moreover, they would require additional funding at a time when the national need and the President's policy is to reduce the growth of Federal expenditures and lower budget deficits. . . . We believe a more efficient use of scarce Federal health dollars can be made in keeping with the Department's ultimate objective of a comprehensive health care system. Within that framework, the promotion of family planning service on a needs basis, particularly through Medicaid and social services, offers much more potential than the addition of one more categorical program (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 22-23).

The rejection of the "School-Age Mother and Child Health Act" of 1975 by the Ford Administration was not unexpected and it raised several criticisms that reappeared in future debates. Whether another separate federal agency had to be created or whether the funds could be better used for existing programs remained major issues. Furthermore, given the high costs of caring for pregnant

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teenagers compared to the low costs of preventing an unintended adolescent pregnancy, either through family life and sex education programs or through the provision of family planning services, many questioned the wisdom of the Kennedy-Bayh approach. The Adolescent Health, Services, and Pregnancy Prevention and Care Act of 1978 The presidential election and not new legislation for pregnant teenagers absorbed most political leaders in 1976.7 But with the election of Jimmy Carter, the proponents of an expanded federal role for school-age mothers saw another opportunity to achieve their goals. A Special Carter Task Force headed by Sargent Shriver and including many of the earlier supporters of the "School-Age Mother and Child Health Act" submitted recommendations for a "Family Development Program" to the new Secretary of DHEW, Joseph Califano on March 17, 1977. The Special Task Force's top priority was the "establishment of Teenage Pregnancy Centers based on the model center at Johns Hopkins University" (U.S., Department of Health, Education, and Welfare, Special Task Force, 1977: 27). The Carter Administration indicated its interest and commitment to this problem by revising the Ford FY1978 budget to include an additional $35 million for helping sexually active adolescents and pregnant teenagers (Washington Memo, March 1, 1977). No mention was made, however, of any need for new legislation to create special centers for pregnant teenagers based on the Johns Hopkins model.8 Efforts to curb teenage pregnancy and to help pregnant adolescents soon became part of a larger initiative within the Carter Administration known as the "Alternatives to Abortion Program" (U.S., Department of Health, Education, and Welfare, Task Force on Alternatives to Abortion, 1977). This approach was also seen as a way of coping with the political difficulties that Carter had encountered on the abortion issue during the 1976 election.9 While most of the advocates calling for more services for adolescents usually denied that the Carter Administration initia-

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tives were simply or mainly a response to the abortion issue, the concern about abortion continued to influence the perceptions and reactions of many public leaders. On June 13, 1977, Califano established another interagency task force on "Adolescent Pregnancy and Related Issues" under the direction of Peter Schuck, the Deputy Assistant Secretary for Planning and Evaluation. The task force, consisting of representatives from each of DHEW's Principal Operating Components, all Assistant Secretaries, and the General Council, deliberated for several months and produced a decision memo for the Secretary on August 4, 1977, that outlined the various options available and provided him with recommendations (U.S., Department of Health, Education, and Welfare, Office of Planning and Evaluation, 1977). The "Adolescent Pregnancy Related Issues" memo, written by Peter Schuck, approached the problems of adolescent pregnancy from a broad perspective. It recommended expanding existing programs as well as introducing "new legislation for comprehensive services to adolescents and families. The new legislation would encompass services for all adolescents, but would give priority to problems related to adolescent pregnancy." In other words, though the DHEW task force did consider the option of a narrow proposal to create comprehensive care centers just for pregnant teenagers, it preferred a more general and flexible approach that would provide assistance for all adolescents and include services from several existing special programs. While the DHEW task force did not agree with Senators Kennedy and Bayh on the need for a separate federal program for pregnant adolescents, it did accept their views on how those services should be provided: Pregnant adolescents require a broad range of health, education and supportive services, which must be delivered through a comprehensive, single-site program or in closely linked programs (U.S., Department of Health, Education, and Welfare, Office of Planning and Evaluation, 1977:4).

The memo recommended the provision of both prevention and care services, but its emphasis was on prevention programs such as

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the Public Health Service Title X Family Planning Program because they "have been demonstrably successful and are cost-effective." Furthermore, Prevention of pregnancy in adolescents is highly desirable because there are limits to the ability of any post-pregnancy intervention, including abortion, to minimize the adverse health, emotional and social consequences of pregnancy (U.S., Department of Health, Education, and Welfare, Office of Planning and Evaluation, 1977: 5).

The memo also noted that "there are major gaps in our knowledge of the problems and solutions to unwanted pregnancy" and recommended expansion of research and evaluation in three areas: (1) social and behavioral research, (2) programs for adolescents, and (3) biomedical research. The memo included a long list of possible research and evaluation topics, including a fairly comprehensive set of recommendations for analyzing family life and sex education, contraceptive services and information, and assistance for pregnant teenagers. These studies would be handled by existing agencies and the memo made no suggestion that any of the research or evaluation might be done by a new agency created by the proposed legislation. Interestingly, though the section of the paper dealing with research and evaluation admitted to the presence of "major gaps" in our knowledge, the rest of the memo spoke confidently about the type of programs needed and their proven effectiveness. Extensive disagreement continued within the Carter Administration in FY1979 over the final version of the proposed Adolescent Pregnancy Initiative. Senator Kennedy, the congressional leader most involved in these discussions, appeared to be more interested in the creation of a new program than the coordination of existing ones at the federal level. The Office of Management and the Budget (OMB), on the other hand, resisted any efforts to create new programs and wanted simply to improve the coordination among existing ones. Furthermore, whereas Califano requested $200 million in new funds for this initiative, OMB reduced it to only $50 million. In the end, after a direct appeal to President Carter, the budget authority for the FY1979 Adolescent Pregnancy Initiative was raised $148 million above that of FY1978—including a sepa-

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rate piece of legislation entitled the "Adolescent Health, Services, and Pregnancy Prevention and Care Act" of 1978, which was to be funded at a level of $60 million (New York Times, January 24, 1978). The 1978 legislation was different from the "School-Age Mother and Child Health Care Act" of 1975 even though the Carter Administration had agreed with Senator Kennedy's suggestion to sponsor new legislation. Unlike the earlier Kennedy bill, the "Adolescent, Health, Services, and Pregnancy Prevention and Care Act" of 1978 provided for primary prevention as well as care services for pregnant teenagers. While the Administration refused to specify what amounts of money should be spent on each activity, clearly primary prevention, including family life and sex education, would be a high priority. Prevention is our first and most basic line of defense against unwanted adolescent pregnancies. The Department's preventive strategy takes several forms, including education on the responsibilities of sexuality and parenting, family planning services. We anticipate that a significant proportion of the $60 million budgeted for our propose program will go to projects providing such family planning and educational services (U.S., Congress, Senate, Committee on Human Resources, 1978: 34).

The Carter Administration's bill also changed the administration of the grants. Rather than channeling money through a designated state agency, funding would be available to any qualified public or nonprofit private agency. Although this did not preclude funding state-wide organizations such as the Delaware Adolescent Pregnancy, Inc. (DAPI), it allowed local adolescent pregnancy centers in cities such as Boston, Baltimore, or New Haven to apply directly for federal aid. The "Adolescent Health, Services, and Pregnancy Prevention and Care Act" of 1978 provided funds either for linking together existing services or establishing new ones in order to provide comprehensive services for teenagers. The bill emphasized linking existing efforts and stipulated that only 50 percent of the money could be used for providing new services. When pressed for any proof that the linkage of services either reduced pregnan-

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cies or helped pregnant teenagers, the Carter Administration did not produce any specific studies but simply pointed to the general success of comprehensive care centers such as the one at Johns Hopkins University. Unlike the "School-Age Mother and Child Health Act" of 1975, the Carter Administration's proposal did not specify which services had to be provided. We do not believe that there is a specific set of core services that should be required to qualify for grants. Since we are hoping, through this program, to learn what "works," we want communities to have the maximum flexibility possible in developing their approaches to the problems of adolescent pregnancy. However, we do expect most communities to link together or directly provide services such as family planning, pre-natal health care, education and counseling (U.S., Congress, House, Committee on Interstate and Foreign Commerce, 1978: 42).

Despite the Carter Administration's stated desire to learn from these projects, they were unwilling to set aside funds for evaluation beyond the normal one percent taken out of all service programs. Thus, though the Carter Administration's bill provided considerable fexibility in allowing local areas to experiment with different mixtures of services for pregnant teenagers, it was not designed to develop and evaluate different models of service delivery. Instead, the Administration viewed the legislation as a traditional, though more flexible, service delivery program. The "Adolescent Health, Services, and Pregnancy Prevention and Care Act" was initially proclaimed by DHEW Secretary Joseph Califano as one of the Carter Administration's top domestic priorities in FY1979, but it did not evoke much support or enthusiasm in the House. The legislation (H.R. 12146) was introduced by Representatives Paul G. Rodgers (D-FL) and John Braedmas (DIN) not on their own behalf, but at the request of the Carter Administration. It was referred jointly to the Subcommittee on Health and the Environment of the Committee on Interstate and Foreign Commerce and the Subcommittee on Select Education of the Education and Labor Committee. Both of these Committees held one day of hearings on the bill and neither made any effort to

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act upon it (U.S., Congress, House, Committee on Interstate and Foreign Commerce, 1978; U.S., Congress, House, Committee on Education and Labor, 1978). The legislation received its most extensive set of hearings in the House from the Select Committee on Population which held three days of hearings on adolescent pregnancy (U.S., Congress, House, Select Committee on Population, 1978a). Indeed, the Select Committee on Population made the most detailed and critical review of this legislation. As Select Committees undertake only oversight activities, it did not exercise as much direct influence on the final decision on this bill as the permanent committees of the House and Senate. But several members of the Select Committee on Population also sat on the two House Subcommittees that did have jurisdiction, so the Select Committee often exercised its influence through them. Furthermore, because the sixteen members of the Select Committee on Population agreed amongst themselves on this legislation while the other two Subcommittees did not try to reach a consensus on the bill, the recommendations of the Select Committee carried some additional weight in the House—especially when the legislation went to the House-Senate Conference Committee. The Select Committee on Population commended the Carter Administration for introducing the "Adolescent Health, Services, and Pregnancy Prevention and Care Act" and agreed on the need for comprehensive services for pregnant teenagers, but felt that "given the profound personal and societal costs of unwanted pregnancy, the primary emphasis of the Administration proposal should be the prevention of such pregnancies" (U.S., Congress, House, Select Committee on Population, 1978b: 93). In particular, the Select Committee felt that most of the funds should be used for family life and sex education programs as family planning money was already available through Title X and other federal programs. The Select Committee agreed on the need for linking existing services for adolescents, but disagreed with the Carter Administration's requirement that at least half of the funds be used for linkage purposes. The Committee felt "that the Administration may have overestimated the extent of such services in most communities. Nonexistent services cannot be coordinated, even if the funds are

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available for this purpose" (U.S., Congress, House, Select Committee on Population, 1978b: 95). Instead, the Select Committee suggested that only up to twenty-five percent of the $60 million be used for linkages. One of the issues that elicited the most opposition to the Administration's proposal among members of the Select Committee on Population was the lack of adequate evaluation money or plans to initiate this. "Given the current state of knowledge in this area, it is imperative that different types of approaches be tried and evaluated to determine which are the most effective" (U.S., Congress, House, Select Committee on Population, 1978b: 95). Therefore, the Select Committee recommended that at least 3 percent of the money be set aside for evaluation and that this portion of the funds be administered through the Center for Population Research (CPR) in the National Institute for Child Health and Human Development (NICHD). Finally, the Select Committee argued that the responsibility for this initiative should be placed within the Office of Population Affairs (OPA) rather than being a separate entity reporting directly to the Assistant Secretary for Health. This effort to designate legislatively the location of the proposed office within DHEW was part of the Select Committee's ongoing attempt to strengthen the Office of Population Affairs in order to provide more coordination for such efforts within the federal bureaucracy.10 In the Senate, the "Adolescent Health, Services and Pregnancy Prevention and Care Act" (S. 2910) was referred directly to the Committee on Human Resources chaired by Senator Harrison A. Williams, Jr. (D-NJ) rather than one of the subcommittees because of overlapping subcommittee jurisdictions. The Committee held extensive and detailed hearings on S. 2910 on June 14, and July 12, 1978 (U.S., Congress, Senate, Committee on Human Resources, 1978). During the hearings, many of the same issues and arguments that had been raised in the House were aired. Several Senators congratulated the Carter Administration on the introduction of this legislation and praised it for its dual mission of preventing initial unintended pregnancies and helping pregnant teenagers. They also agreed with the flexible guidelines for the provision of comprehensive services, but expressed some doubts about the lack

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of an adequate evaluation plan. As Senator Richard S. Schweiker (R-PA) put it: The bill does establish an evaluation program, but, as I read it, does not require an evaluation component for each program. I wonder if some oversight evaluation really is not desirable in that respect. Lack of evaluation seems to be one of our problems in Washington generally. And since you do have an evaluation program per se, could we not require an evaluation component for each program and to see, is it doing the job, is reaching the teens, is really responding to the needs? (U.S., Congress, Senate, Committee on Human Resources, 1978: 47) Secretary Califano responded by assuring the senators that he felt the evaluation of this initiative was very important and that the language of the bill would be strengthened if necessary. We will have an evaluation component with every program. Indeed, at the same time that we put this office fully into operation, we will start an evaluation of the office itself in Washington. So, I agree 100 percent with that. I think the bill does, in effect, provide for that. If the language is not tough enough or strict enough, we have no objection to making it clear, because that is what I intended to do (U.S., Congress, Senate, Committee on Human Resources, 1978: 47). A coalition of outside groups involved with the issue of adolescent pregnancy also affected the final outcome of this legislation by attempting to reorder its priorities. Led by Eunice Shriver, Executive President of the Joseph P. Kennedy, Jr., Foundation, and Janet Bell Forbush, Executive Director of the National Alliance Concerned with School-Age Parents (NACSAP), the coalition wanted most of the funds of S. 2910 to be spent on comprehensive services for pregnant teenagers rather than prevention of initial unintended pregnancies. As Forbush testified: Therefore, since S. 2910 represents only one element of the Department of Health, Education, and Welfare's proposed Teenage Pregnancy Initiative and, in light of recent passage of family planning legislation which includes funding for services intended for adoles-

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AN "EPIDEMIC" OF ADOLESCENT PREGNANCY? cents, NACSAP recommends that the primary—though not exclusive—emphasis of this bill be on the needs of pregnant adolescents, young parents, their infants and extended families. It is this population which has been underserved or unserved in most communities and it is this group of families whose needs are so comprehensive as to be overwhelming . . . (U.S., Congress, Senate, Committee on Human Resources, 1978: 284).

In other words, the coalition of groups led by the Joseph P. Kennedy, Jr., Foundation and NACSAP saw S. 2910 as an opportunity to resurrect the legislation they had tried to enact three years earlier—the "School-Age Mother and Child Health Act" of 1975. By placing most of the emphasis of this bill on services for pregnant teenagers and establishing a set of mandatory core services, the Carter Administration's bill could be transformed into the earlier proposal, which had emphasized care rather than prevention. To convince the senators to change the Administration's proposed legislation, the coalition had to persuade them that prevention programs were ineffective or that family planning services already received adequate funding through other federal programs (such as the Title X Family Planning Services Program). The notion that many, if not most, pregnant teenagers wanted to have children was mentioned by several witnesses (U.S., Congress, Senate, Committee on Human Resources, 1978: 41, 136, 410, 636– 637), but few produced evidence to support this interpretation. On the contrary, considerable testimony stressed the effectiveness of family planning programs in reducing adolescent pregnancies and both the Carter Administration and most congressmen accepted this perspective.11 The congressmen were influenced, however, by the fact that a large increase had already been voted for family planning under Title X and that a large proportion of these new funds were designated specifically for adolescents. Even some organizations that believed in the efficacy of family planning programs and wanted more federal support for prevention, did not oppose the transformation of S. 2910 into a bill mainly for services for pregnant teenagers. Faye Wattleton, for example, President of the Planned Parenthood Federation of America, deplored the lack of specificity in S. 2910 and suggested the establishment of "a program of comprehensive supportive services for preg-

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nant teenagers, teen parents, and their babies" (U.S., Congress, Senate, Committee on Human Resources, 1978a: 195). A few of the witnesses who felt that most of the funds of S. 2910 should be used for services for pregnant teenagers still argued for preventive services. They reasoned that this new program could develop more innovative ways of reaching adolescents—especially before they became sexually active. Thus, Marjory Mecklenburg, President of American Citizens Concerned for Life observed: I personally don't believe that anything is gained by withholding family planning services from adolescents after they are sexually active. Such a policy only increases the possibility of pregnancy, pressure for abortions and other problems sexually active teenagers may have. However, contracepting adolescents is not the only or optimum solution to preventing adolescent pregnancy. Many of us would like to see programs which would encourage young people to choose to value themselves and their sexuality and to postpone sexual involvement. Yet today there appears to be little emphasis on this approach and little encouragement for adolescents who choose this option. Current role models tend to glamorize the sexually active teen (U.S., Congress, Senate, Committee on Human Resources, 1978a: 439-440).

The coalition on adolescent pregnancy led by the Joseph P. Kennedy, Jr., Foundation and NACSAP also wanted a mandatory minimum set of core services for pregnant teenagers that all comprehensive centers would have to provide. Janet Forbush listed what services NACSAP considered to be a minimum in the areas of health, education, and social services and insisted that "all should be available to pregnant teenagers and their families during the course of a pregnancy and for a minimum of two years following delivery . . ." (U.S., Congress, Senate, Committee on Human Resources, 1978a: 288). Again, though some individuals and organizations spoke strongly for mandatory core services, no one produced evidence demonstrating which ones were really essential. Instead, many simply assumed that the configuration of core services recommended by this coalition, based in large part on the experiences at centers such as Johns Hopkins and DAPI, were indispensable. This warranted mandating them although insisting on core services meant sacrificing the flexibility of the Carter Ad-

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ministration's proposal and limiting the ability of centers to develop more innovative approaches. During the Senate debates some opposition did emerge, and called the legislation unnecessary and wasteful. Although the bill had received strong bipartisan support at the hearings, a few conservative Republicans openly opposed it. Senator S.I. Hayakawa (RCA) challenged the underlying assumption that the legislation would reduce teenage pregnancies: "Pregnant girls, in other words, are in an extraordinarily enviable position in some school systems in California where they are so very, very well taken care of. And if we increase the rewards, the attractiveness of teenage pregnancy, well, we simply increase teenage pregnancy" (U.S., Congress, Senate, Committee on Human Resources, 1978a: 89). After the public hearings in the House and Senate, most observers assumed that the "Adolescent Health, Services, and Pregnancy Prevention and Care Act" of 1978 would not be enacted by the 95th Congress. Little enthusiasm could be found for it in the House and the Carter Administration did not make it a top legislative priority in the fall of 1978. In addition, the senators remained divided on whether most of the funds should be spent for primary prevention or services for pregnant teenagers. Finally, a few senators even doubted the necessity or desirability of the legislation at all. Primarily because of Senator Kennedy's interest in this legislation as well as his influence among his colleagues, the Senate Committee on Human Resources considered S. 2910 in an open executive session on August 25, 1978, and approved an amended version of this bill. Following the recommendations of the coalition on adolescent pregnancy, the Committee rewrote the Administration's proposal in order to emphasize services for pregnant teenagers. Recognizing the increasing emphasis of Title X and other family planning programs on adolescents, it is the view of the Committee that this initiative should build upon, not duplicate, Title X and other similar prevention oriented program efforts. Based on these expanded efforts, the Committee believes that a priority of services paid for with funds under the reported bill must be steered to address the needs of pregnant adolescents and pregnant teenagers . . .(U.S., Congress, Senate, Committee on Human Resources, 1978b: 16).

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The Senate Committee also rejected the Carter Administration's more flexible approach by insisting that a core set of ten services be provided by all grantees. The bill requires that every grantee must provide, either in a single site setting or through a network of comprehensive services, certain essential "core" services to eligible adolescents. The Committee heard compelling arguments for this requirement and believes that all the core services defined in this bill are absolutely key components to a comprehensive strategy to address the total picture of adolescent pregnancy. This should not be construed, however, to be interpreted that these core services are the sole or exclusive services which are critical to pregnant adolescents or adolescent mothers. The Committee recognizes that other educational, vocational, and social services play a crucial role in the overall outcome for these adolescents and thereby, believes that it would be useful if these were incorporated as part of a comprehensive network of services . . . (U.S., Congress, Senate, Committee on Human Resources, 1978b: 18). Although the Committee rejected the Carter Administration's emphasis on primary prevention in the original bill, it did include some provisions for it by calling for the development of more innovative family life and sex education programs. The Committee supports the development of creative educational approaches to pregnancy prevention through this legislative initiative. It is the view of the Committee that significant strides may be made if innovative experimental approaches to deter adolescents from early pregnancy are coordinated with a comprehensive program as advocated in the Committee bill. The Committee believes that family life and sex education provided under this act should involve participation by the community, including parents, and to the maximum extent feasible health professionals, ministers, educators, social workers, ethicists, etc., so that a supportive environment can be created for the adolescents who participate (U.S., Congress, Committee on Human Resources, 1978b: 16). The Committee heeded the recommendations of several individuals and groups and dropped the requirement that at least 50 percent

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of the funds be spent onlinkage of services. In addition, the Committee decided that the evaluation effort under this proposal should be expanded, and directed that up to 3 percent of the funds could be used for this purpose. Furthermore, the Committee, in a somewhat unusual provision, assigned "the responsibilities for evaluation of the program to a unit other than that unit having primary administrative responsibility for administering the grant program" and recommended that "consideration" be given to "designating the Center for Population Research (CPR) of the National Institute for Child Health and Human Development as the unit responsible for overseeing the evaluation of these programs" (U.S., Congress, Senate, Committee on Human Resources, 1978b: 21). The major disagreement within the Committee was over the issue of abortion counseling. Senator Schweiker had amended the Administration's proposal to read that "assurances that each pregnant adolescent receiving services will be advised of the availability of counseling (furnished either by the entity providing core services or through a referral agreement with such other entity which provides such counseling) on all options regarding her pregnancy." Senator Stafford, arguing that this "does not ensure adequate counseling to pregnant teenagers" on all options, offered an amendment requiring that "assurance that each pregnant adolescent receiving services would be informed of counseling (furnished either by the entity or through a referral agreement with such other entity which provides such counseling) on all options regarding her pregnancy." The Stafford amendment was defeated eight to six and the Schweiker amendment that "no funds for grants made under provisions of the Act may be used for payment for the performance of an abortion" was adopted unanimously (U.S., Congress, Senate, Committee on Human Resources, 1978b: 23). The Senate Committee on Human Resources adopted the amended version of S. 2910 though two senators, Hayakawa and Hatch, dissented and filled minority views. Senator Orrin G. Hatch (R-Utah), who would cosponsor the 1981 legislation on adolescent pregnancy, rejected this bill along the same lines as the Ford Administration had opposed the "School-Age Mother and Child Health Act"—as being unnecessary and duplicative of existing programs.

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There are currently 15-20 federally funded programs concerned with some aspect of teenage pregnancy, childbearing, and parenting. Government expenditures associated with welfare payments, food stamps, medical costs and social services for this group are estimated to be in the range of $1-3 billion a year. Adding another $60, 70 or 80 million which this bill will require to establish an even larger bureaucracy will not help. It will create even more paperwork and more confusion to an already regulated over-burdened State. Although, the teenage pregnancy situation is one which deserves heightened attention, I believe that S. 2910 is a poor route to take. . . . There are many programs in existence now which have been expanded in the FY1979 budget that include targeting on teenagers. The President has requested in the area of $344 million for programs that address this problem—an increase of $148 million over current efforts. Let's give this a chance before enacting unnecessary duplicative legislation (U.S., Congress, Senate, Committee on Human Resources, 1978b: 32).

The bill, authorized at levels of $60 million for FY1979, $70 million for FY1980, and $80 million for FY1981, passed the Senate Committee on Human Resources and perhaps would have been adopted by the full Senate as a separate measure, except that neither of the two House Subcommittees with jurisdiction over it made any effort to act upon it. Senator Kennedy, on behalf of himself and eight other senators, then moved on the floor to attach S. 2910 as an amendment to the "Health Services Extension and Primary Health Care Act" (S. 2474) on September 29, 1978 (U.S., Congress, Congressional Record). By attaching the bill to one that the House had already acted upon, Senator Kennedy cleverly ensured that S. 2910 would be considered by at least a Senate-House Conference Committee in the 95th Congress. When the "Adolescent Health, Services, and Pregnancy Prevention and Care Act" was proposed as an amendment, Senator Stafford reintroduced his amendment guaranteeing that all adolescents receive abortion counseling. Again, this amendment was opposed by several other senators including Kennedy and Schweiker. The Stafford amendment lost on a roll call vote 66 to 19 (U.S., Congress, Congressional Record, September 29, 1978: S16597).

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Senator Jesse A. Helms (R-NC) then introduced a parental notification amendment. . . . no program or project which directly or indirectly receives funds under this title may prescribe or dispense any prescription contraceptive drug or device to an unemancipated child under the age of 16 unless the parent or guardian of this child is notified of the intent to prescribe or dispense such drugs or devices (U.S., Congress, Congressional Record, September 29, 1978: S16597).

Although the proposed parental notification regulations for the Title X Family Planning Services under the Reagan Administration evoked sharp opposition in 1982, the Helms's amendment did not arouse any opposition on the floor of the Senate. Senators Kennedy and Schweiker both supported the Helms's amendment as "worthwhile" and it was accepted without dissent from the other senators. Because some senators opposed the "Adolescent Health, Services, and Pregnancy Prevention and Care Act" altogether, Senator Malcolm Wallop (R-WY) planned to submit a substitute measure that only called for a federally funded study of adolescent pregnancy. After consultation with the managers of the bill, however, Wallop withdrew his motion to strike the Kennedy amendment and to substitute his own. Senator Kennedy agreed to attach the Wallop amendment to his own bill and added a one-year independent study of adolescent pregnancy with funding up to $500,000 as a separate section of the bill. The study shall evaluate the effectiveness of existing programs relating to health, education, and public welfare, as they relate to this program, and shall include suggestions as to the most effective means of reducing or eliminating unwanted adolescent pregnancies . . . (U.S., Congress, Congressional Record, September 29, 1978: S16600).

Thus, although neither the "School-Age Mother and Child Health Act" of 1975 nor the Carter Administration's original bill had envisioned a major evaluation component under this legislation, the final Senate version mandated several major evaluation activities including a full-scale study of the entire problem.

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Having been passed as an amendment to the "Health Services Extension and Primary Health Care Act" in the Senate but not in the House, the legislation went to a House-Senate Conference Committee on October 15, 1978. Many observers assumed that the adolescent pregnancy portion of this legislation would be deleted in the Conference Committee because most House members had shown little interest. In addition, while many representatives and senators felt that something should be done about adolescent pregnancy, they were not very happy with the final version of this bill. There was a growing realization, however, that unless legislation passed in the closing days of the 95th Congress, the next Congress probably would not enact it because of the "taxpayer's revolts" in states such as California. Therefore, Representative James H. Scheuer (D-NY), Chairman of the House Select Committee on Population, urged that the Conference Committee accept the Senate amendment on adolescent pregnancy even though he and many other members had serious reservations about parts of the legislation. Representative Scheuer failed to place the adolescent pregnancy initiative under the Deputy Assistant Secretary for Population Affairs (DASPA). Instead, the conferees agreed that the program unit responsible for carrying out the activities should report directly to the Assistant Secretary for Health in consultation and in coordination with the Deputy Assistant Secretary for Population Affairs. The attempt to place a parental notification requirement on the Title X Family Planning Services legislation had just failed in the House, so the conferees agreed to drop the parental notification requirement from this legislation. In addition, they reduced the authorization for this portion of the legislation to $50 million for FY1979, $65 million for FY1980, and $75 million for FY1981. Although the final version of the "Adolescent Health, Services, and Pregnancy Prevention and Care Act" of 1978 in some ways looked more like the earlier "School-Age Mother and Child Health Act" than the original Carter Administration bill, it did include provisions for family life and sex education programs and more funds for evaluation purposes. Yet the visible lack of support for this legislation, especially in the House, portended the difficulties that lay ahead in the appropriations process. Although the coalition of individuals and groups that had lobbied on behalf of this legislation had finally achieved their goal of a federal service

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program primarily for pregnant teenagers, the alteration of the legislation in the Senate significantly alienated many representatives and senators who would not be very supportive of the new Office of Adolescent Pregnancy Programs (OAPP).

Office of Adolescent Pregnancy Programs under Lulu Mae Nix Although President Carter did not sign the legislation establishing the Office of Adolescent Pregnancy Programs until November 10, 1978, Secretary Califano announced the appointment of Dr. Lulu Mae Nix, the Director of the Delaware Adolescent Pregnancy Program, to manage the teenage pregnancy initiative within the department on April 13, 1978—the same day that he announced the transmission of the "Adolescent Health, Services, and Pregnancy Prevention and Care Act" to the Congress (U.S., Department of Health, Education, and Welfare, HEW News, April 13, 1978). Throughout the deliberations in Congress about the fate of this bill, Lulu Mae Nix played an important role in pushing for this legislation and worked closely with the informal coalition that had supported the final amended version of this bill.12 Considerable concern had been expressed that the Office of Adolescent Pregnancy Programs (OAPP) would not be provided with adequate staffing; several representatives and senators even questioned the Carter Administration about it. During the months between April and the final enactment of the legislation in November, Lulu Mae Nix tried to assemble a staff in order to carry out the coordinating tasks assigned to her by the Secretary. On August 2, 1978, the Carter Administration revealed its proposed staffing for the Office of Adolescent Pregnancy Programs. The plans called for OAPP to have forty professionals and sixteen support staff. The Office of Adolescent Pregnancy Programs would be subdivided into three divisions—(1) Program Development, (2) Program Monitoring, and (3) Program Planning, Evaluation, and Integration. Whereas earlier Administration discussions of OAPP had not indicated a major commitment to planning and evaluation, the staffing plan suggested a change in emphasis as

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eight professionals and two support staff were allocated for these functions (U.S., Congress, House, Committee on Education and Labor, 1978: 314). At first glance, it seemed that the Office of Adolescent Pregnancy Programs was in an excellent position. The legislation in November had just authorized $50 million for FY1979 and the Carter Administration committed itself adequate staffing even in the event of a job freeze because "this initiative is of the highest priority in the Department" (U.S., Congress, House, Committee on Education and Labor, 1978: 314). Yet a series of unforeseen events occurred that severely hampered the functioning of OAPP.13 Because the legislation was not enacted until the closing days of the 95th Congress, it did not become part of the regular FY1979 appropriations process. Instead, the Carter Administration included OAPP in a supplemental budget request, but only at a level of $7.5 million, not the the $50 million level authorized by the 95th Congress (or the $60 million in the initial Carter Administration bill). The situation for OAPP became even more difficult when the Congress did not approve the supplemental budget until July 1979, and then provided only $1 million. Thus, during most of its first year of operation, the Office of Adolescent Pregnancy Programs was not funded and then received only $1 million very late in the fiscal year. Lacking direct funding, the Office of Adolescent Pregnancy Programs had to survive on the small amounts of money made available to it by the Department. Rather than being allowed to fill the fifty-six anticipated positions, OAPP only had nine employees by the end of 1979 and thirteen by the end of 1980.14 Though OAPP offset some of the lack of permanent staffing by hiring outside consultants, the lack of permanent employees hampered the performance of OAPP functions in Washington.15 The unanticipated changes in staffing due to the lack of adequate appropriations introduced fundamental changes in the structuring and functioning of OAPP. No one was hired, for example, for the Division of Program Planning, Evaluation, and Integration (U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs, 1981a). Although OAPP was supposed to have strong planning and evaluation capability, the lack

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of congressional appropriations and the unwillingness of the Carter Administration to provide more staffing resulted in a major change in the functioning of OAPP. OAPP solicited proposals for funding for FY1979 and received 211 applications—sixty-two of which the review panels approved. Due to the shortage of funds, only four projects received funding for FY1979. The regulations for these programs were first advertised in the Federal Register on March 12, 1979, and finalized July 23, 1979; a draft of program guidance materials for grantees was distributed in January 1980. The future of OAPP looked more hopeful for FY1980 as Congress appropriated $17.5 million. Dr. Nix introduced a new structure for the grants by designating five separate categories under which organizations applying for funds would be considered (U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs, 1980: 5): 1. Single-site programs—all core services delivered in one location. 2. Linkage programs—core services at several locations in a coordinated delivery system. 3. Rural programs—single site or coordinated with outreach services to inaccessible areas. 4. Statewide, countywide, and citywide programs—coordination of a network of interacting programs and services. 5. Research program—core service delivery system with a separate research unit.

The Office of Adolescent Pregnancy Programs continued its emphasis on providing comprehensive services for pregnant teenagers. Yet it now also expressed its commitment to the prevention of adolescent pregnancies through improved education programs for teenagers. The legislation supports the development of creative educational approaches to pregnancy prevention and the Office of Adolescent Pregnancy Programs encourages programs to develop innovative ways to deter adolescents from early pregnancy. States receiving OAPP funds will be required to improve delivery of pregnancy prevention and related services and coordinate these activities with

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local organizations funded under this program. . . . In addition, programs will be evaluated on their efforts to prevent repeat pregnancies among the adolescents they serve (U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs, 1980:13). The Office of Adolescent Pregnancy Programs interpreted its mandate for evaluation under Section VII to include both an independent evaluation of all OAPP activities and an evaluation of each of the projects it funded. The latter requirement was specified as: Each project funded by OAPP will be required to participate in the evaluation process in a number of ways. One will be to incorporate into the grant application a listing of specific objectives of the project, a time table for the implementing of the procedures designed to attain the objectives, and a procedure or procedures to assess and measure periodically and regularly the progress being made toward attaining the objective. Another will be the requirement that all projects funded under the Act will collect certain basic data on the project, procedures used, client population, and the outcomes of the service delivery provided (U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs, 1980:11). Thus, the goals of the program, as espoused by Nix, reiterated OAPP's commitment mainly to serving pregnant teenagers, but allowed the use of some of the funds for educational services to prevent adolescent pregnancies as well. Futhermore, though the Division of Program Planning, Evaluation, and Integration had not materialized due to staff shortages, Nix reaffirmed her commitment to an indepth evaluation of the whole program and the individual grantees. Again, an unexpected budgetary crisis upset the plans of the Office of Adolescent Pregnancy Programs. Although the Congress had funded the program at $17.5 million for FY1980, the President and the Congress decided to rescind $10 million as part of the larger effort to reduce overall federal spending. Consequently, OAPP only had about $5.8 million for new programs in FY1980 instead of the anticipated $13 million.

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Altogether, 380 applicants sought funding in FY1980 and half of the proposals were approved by the review panels. Due to the reduction in funding, however, OAPP awarded only twenty-seven grants, which provided money for thirty-five new and continuing comprehensive services projects (U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs, 1981). Interestingly, Nix decided not to fund any of the research-oriented projects despite the specific category she had created earlier in the grant application process. The decisions to eliminate the research and evaluation aspects of individual programs whenever faced with budgetary restraints became characteristic of the Office of Adolescent Pregnancy Programs under Nix. In fact, OAPP eliminated funds for data gathering and evaluation from the budgets of several of the grantees despite its earlier public announcements of support for such activities. Rather than spending federal money to evaluate alternative ways of delivering services, Nix preferred to use the limited funds for the provision or coordination of those services. As a result, the Office of Adolescent Pregnancy Programs became simply another service delivery agency in the Department of Health and Human Services both in terms of its staff and the type of grant it funded.16 Another characteristic of the activities of the Office of Adolescent Pregnancy Programs under Nix was the growing emphasis on catering to the needs of pregnant teenagers rather than trying to prevent initial, unintended pregnancies. Although the legislation as well as the public announcements from OAPP stressed primary prevention, Nix did not develop this aspect of the program. In fact, OAPP criticized applicants for focusing too much on family life and sex education rather than providing academic training for pregnant teens. The significance of education as part of the comprehensive services program was not fully understood by many of those applying for fiscal 1979 funding. "Referral to appropriate educational and vocational services" is listed under section H of the regulations as one of the essential services. Some applicants interpreted education to mean only sex education, family planning, and parenting courses. The need for an academic program to permit the student to complete high school was inadequately handled or over-looked in many

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applications (U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs, 1980: 9).

If OAPP under Nix abandoned much of its commitment to evaluation and primary prevention, it expended considerable effort to stimulate and coordinate the activities of individuals and groups concerned with adolescent pregnancy. Representatives of 17 national organizations met in Washington D.C. to map strategy for a national conference on adolescent pregnancy to be sponsored by OAPP for the spring of 1981—in part designed to coincide with the reauthorization of the legislation by the Congress. Nix also designated representatives from health, education, and human development agencies in each of the ten DHHS region stoserve as regional coordinators for OAPP activities (U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs, 1981:1–2). Budgetary cutbacks as well as the orientation of Director Nix resulted in much less emphasis on evaluation by OAPP than had been anticipated. Nevertheless, some evaluation and research was initiated because of the requirements in sections VII and VIII of the legislation. The Urban Institute won the contract to conduct the outside evaluation of OAPP and its grantees and devised a uniform system of data collection for each of the twenty-six grantees funded during FY1980. The responsibilities for the evaluation activities by the Urban Institute were shared by the Office of the Assistant Secretary for Planning and Evaluation and the Office of Health Planning and Evaluation in the Office of the Assistant Secretary for Health. Although these two offices and the Urban Institute expected to work closely with OAPP, this did not occur, because Nix was very disappointed that the Urban Institute had won the evaluation contract. There was considerable fear that an indepth, objective review might conclude that care programs for pregnant teenagers were not an effective way of dealing with the problem of adolescent pregnancy. Fortunately, most of the grantees welcomed the efforts of the Urban Institute in helping them set up a uniform system of gathering data for their quarterly reports and the overall evaluation. Thus, although OAPP was unwilling to cooperate with the Urban Institute staff in carrying out the provisions under Sec-

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tion VII, the work was initiated anyway. Further expansion of the evaluation process took place when Marjory Mecklenburg replaced Lulu Mae Nix as the Director of the Office of Adolescent Pregnancy Programs in March 1981. The Office of Adolescent Pregnancy Programs happily selected JRB Associates to perform the required investigation under section VIII of the legislation to conduct "a study on the problem of adolescent pregnancy", which "shall evaluate the effectiveness of existing programs relating to health, education, and public welfare, as they relate to this problem and shall include suggestions as to the most effective means for reducing or eliminating unwanted adolescent pregnancies" (JRB, 1981). JRB Associates had worked closely with the Joseph F. Kennedy, Jr., Foundation and was highly supportive of Nix's approach to serving pregnant adolescents and young mothers. Thus, OAPP cooperated fully with JRB and saw its investigation as a means of documenting the need for the expansion of the existing program. The Enactment of the Adolescent Family Life Program in 1981 If President Carter had been reelected in 1980, it is likely that the Office of Adolescent Pregnancy Programs would have continued as a small service program for pregnant teenagers and young mothers in the Department of Health and Human Services. Although the continuation of OAPP seemed assured because of support inside and outside the Department, neither the Carter Administration nor the Congress tried to fund the program beyond the $10 million allocated for FY1981. The election of Ronald Reagan and the unexpected loss of control of the Senate by the Democrats suddenly threatened the very existence of OAPP as well as many other federal programs; the Republicans had campaigned on a platform of reducing federal domestic programs. Although nothing specific had been said about OAPP during the campaign, the new Administration hoped either to eliminate many of the DHHS programs or to reduce their size and scope significantly by placing them in general block grants instead of allowing them to continue as separate, categorical programs.

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As one of its last responsibilities, the Carter Administration had to submit a FY1982 budget even though it expected that the Reagan Administration would implement changes. Because the initial authorizing legislation for OAPP was scheduled to end in 1981, the Carter Administration recommended a simple extension of Title VI and requested the same level of funding for FY1982 ($10 million) (Washington Memo, Feb. 5, 1981). Instead of assuming that she would be replaced by the incoming Reagan Administration as most other political appointees, Lulu Mae Nix, one of the few black Republicans in the Carter Administration, hoped to remain as the Director of OAPP and recommended the continuation of the program (U.S., Department of Health and Human Services, 1981a). Indeed, Dr. Nix even claimed that the new Secretary of DHHS, Richard S. Schweiker, had decided to keep her (Wilmington News Journal, November 23, 1981: C1). Yet she was quickly replaced in March 1981 by Marjory Mecklenburg, a prominent "pro-life" leader, who had been very active on behalf of programs to help pregnant teenagers and had worked closely with Schweiker during his days in the Senate. Despite the appointment of Marjory Mecklenburg as the new Director of OAPP, the Reagan Administration proposed that the program be placed in the new Maternal and Child Health Services Block Grant. Although Senator Edward Kennedy, now the ranking Minority Member of the Senate Labor and Human Resources Committee, introduced S. 1102 to reauthorize the Title VI Adolescent Pregnancy Program (as well as several other categorical health programs including the Title X Family Planning Services Program), the bill had little chance of passing in the Republican controlled Senate (Congressional Record, May 4, 1981: S4323S4328). On the House side, Representative Henry Waxman (DCA) did introduce legislation (H.R. 2807) to reauthorize both the Title X and Title VI programs, but later readily accepted the inclusion of the Title VI Adolescent Pregnancy Program in the block grant once he perceived its potential as a bargaining chip (after Senator Jeremiah Denton (R-AL) showed interest in enacting a revised form of the Title VI legislation) (Washington Memo, June 5, 1981). In other words, the Adolescent Pregnancy Program had little chance of surviving as a categorical program. The opposition of the Reagan Administration, the unwillingness of the Republi-

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cans in the Senate to accept the Title VI program in its present form, and the relative lack of interest in it by the House, except as a possible bargaining chip to save the Title X Family Planning Services Program, all pointed to the end of OAPP's independent existence. The Republican control of the Senate led to significant changes in the leadership of domestic programs in that chamber. Particularly important, from the perspective of adolescent pregnancy, was the selection of the newly elected senator from Alabama, Jeremiah Denton, as the Chairman of the Subcommittee on Aging, Family and Human Services of the Senate Committee on Labor and Human Resources. Deeply upset by the great increases in premarital sex among adolescents in the United States, Senator Denton laid much of the blame for this development on the federally funded family planning clinics. We should keep in mind that the original goal of family planning was to allow parents the option of planning the size of their family and the spacing of their children if they so desire. However, since the title X program began, we have seen a steady shift away from this original goal in family planning. Increasingly, it appears that family planning clinics are serving teenagers in the absence of their parents advice and counsel and often in contradiction of laws concerning sexual conduct in many of their own States. Moreover, in the role of sex educators, these clinics are promulgating their version of morality in contradiction often to the values of the teenagers' parents and pastors. If we start with the assumption and establish in the minds of our young that premarital sexual intercourse among children is acceptable and inevitable, then I believe we will see a continued growth of the problems attending teenage pregnancy and promiscuity which have marked so many young lives—indeed we will see a continued growth of other extremely dangerous and related sociological problems. As we look back over the past decade, we may find that in many cases we are funding the very problems we set out to eliminate. Furthermore, because family planning clinics do use Federal funds, we may be projecting an inadvertent message of Federal approval for certain values and activities which generally conflict as said before with that of parents and pastors (U.S., Congress, Senate, Committee on Labor and Human Resources, 1981a: 2–3).

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Senator Denton was determined to reverse the increases in premarital sex by sponsoring legislation to encourage sexual abstinence among teenagers prior to marriage. He was placed in a difficult position, however; as a conservative Republican he was generally strongly opposed to the expansion of any domestic federal programs—a position reinforced by the fact that President Reagan and other conservatives were in the midst of a major effort to reduce or eliminate many existing programs including the Title VI Adolescent Pregnancy Program. The solution to this dilemma was to accept placing the existing Title VI Adolescent Pregnancy Program, which was basically a service program for pregnant adolescents and young mothers, into a block grant and to introduce new legislation to encourage teenagers to abstain from premarital sexual activity. In order to avoid the accusation that he was simply starting still another massive federal domestic program, Senator Denton called only for a small demonstration and research program to initiate and evaluate different models of service delivery, which could then be adopted and funded by states and local areas. While this approach still might not please all conservatives, at least in principle it seemed consistent with the notion that the federal government should not fund services that could be provided by private agencies or local and state governments.17 In an attempt to garner support from Catholics, which was an essential part of his strategy to mute any criticisms of the legislation from the right, Senator Denton used the National Conference of Catholic Charities (1981) proposed revision of the Title VI legislation as his point of departure for the new bill. The Catholic Charities draft called for comprehensive services for pregnant teenagers and young mothers without mandating any specific set of core services as Title VI had. Even more important, the bill encouraged research and evaluation by requiring that at least 40 percent of the funds be used for those purposes. The emphasis on research and evaluation in the Catholic Charities bill complemented Denton's intellectual and political approach to this problem and provided a convenient rationalization for moving away from Senator Kennedy's more narrow focus on the provision of services. Denton's proposed legislation for an Adolescent Family Life Program (S. 1090) incorporated much of the language and features

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of the Catholic Charities proposal—including the need for comprehensive services for pregnant teenagers and support for research and evaluation (Congressional Record, April 30, 1981: S4261S4267). But it significantly changed the direction and tenor of the legislation by calling for the prevention of premarital sexual activity among teenagers and emphasizing the promotion of adoption as an alternative for adolescent parents. In addition, the bill required that "the applicant will notify parents of any unemancipated minor requesting necessary services from the applicant and will obtain the permission of such parents with respect to the provision of such services." Furthermore, whereas the Catholic Charities proposal only stated that none of the funds could be used for abortions, the Denton bill went much further by stating that "no recipient of assistance under this title may provide abortion counseling or referral, make any payment for the performance of an abortion, or conduct any research relating to abortion, except that a recipient of a grant or contract under section 1908 may conduct research relating to the negative consequences of abortion." Although some of the specific changes in the Denton proposal became points of contention during the debates over S. 1090, the "findings and purposes" section of the legislation proved more controversial, even though the statements in this section would have had little direct impact on the actual implementation of the program. The symbolic issues raised by this legislation frequently led to emotional, moralistic outbursts from both its supporters and opponents and illustrates how the nature of the debate over adolescent pregnancy in 1981 had changed from 1975 or 1978. The idea that federal funds should be used to prevent initial, unintended pregnancies rather than just helping pregnant teenagers was not particularly new; the Carter Administration and many congressmen had taken such a position in 1978. Even the use of those funds to discourage early adolescent sexual activity rather than just funding more family planning services was not a radical departure. Congressmen in 1978 had urged that the Title VI legislation encompass such activities. But the language used in the Denton bill to condemn any premarital sexual activity created a furor among many individuals who agreed in principle with the need for reducing adolescent premarital sex, but were revolted by the specific wording of the legislation. On the other hand, many conserva-

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tives, initially opposed to the legislation as an unnecessary and unwarranted expansion of federal domestic programs, applauded Denton's strong and unequivocal condemnation of premarital sexual activity among adolescents. The controversy stemmed from the "findings and purposes" section of S. 1090 (Congressional Record, April 30, 1981: S4262) where the first reason for the legislation was "to promote selfdiscipline and chastity, and other positive, family-centered approaches to the problems of adolescent promiscuity and adolescent behavior." There could be no question of the symbolic meaning of Denton's approach; the bill bluntly asserted that " 'promiscuity' means having sexual intercourse out of wedlock."18 Despite the sharp injunctions against premarital sex and the strong "pro-life" provisions in the bill, many conservatives still opposed it. The Library Court group, an assembly of active Washington conservatives with whom Denton frequently dined, admitted that his bill represented a major improvement over the previous legislation, but nevertheless opposed it 17 to 0 just before the bill first appeared in the Congressional Record (April 30, 1981). They saw the proposed legislation as an unnecessary continuation of federal programs at a time when the Reagan Administration was trying to eliminate such efforts. Denton was shaken by the strong opposition from his conservative friends and this initially limited his ability and willingness to compromise on the more controversial and symbolic aspects of the legislation. But as the liberal establishment (New York Times, July 17, 1981) vigorously attacked the Denton bill, many conservatives, especially those in the Senate, changed their position on the legislation. Particularly important was the strong and consistent support for this bill from the Chairman of the Senate Committee on Labor and Human Resources, Orrin Hatch. Denton may have been able to obtain enough votes in the Senate to enact his bill, although several moderate Republicans and many Democrats disagreed with his approach, but he clearly lacked the support necessary to pass it in the House. Indeed, throughout the legislative process, Denton expressed concern that Senator Kennedy and Representative Waxman would suddenly reauthorize the old Title VI legislation in the House and convince members of the Senate-House Conference Committee to emaciate

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the crucial parts of the Denton bill. Or even more likely, Representative Waxman would block the passage of the S. 1090 in the House by killing it in his Subcommittee. As a result of his need for political support, Denton turned to Kennedy, who had been so instrumental in the passage of the Title VI legislation in 1978. Senator Kennedy was also interested in such an alliance because he gradually realized that he lacked the votes to reauthorize the Title VI bill. But Kennedy strongly objected to four aspects of the Denton bill: 1. Kennedy found the specific wording of the chastity/promiscuity sections of the legislation unacceptable because he did not want to be associated with anything so harshly condemning the sexual activity of teenagers. 2. The strong adoption language seemed inappropriate, but Kennedy, after some timely lobbying by the advocates of adoption, dropped his objections to this provision. 3. The research and evaluation orientation of the proposed legislation threatened to divert funds from services for pregnant teenagers and young mothers. 4. Kennedy saw the proposed language on abortion as too strong because it would eliminate projects such as the Johns Hopkins Program from continued federal funding (the Joseph P. Kennedy, Jr., Foundation had a very large commitment to the work at Johns Hopkins University and was determined to preserve it). The actors involved found the symbolic issues much harder to resolve than the substantive ones. Although neither Denton nor Hatch were personally irrevocably wedded to the strong wording on teenage promiscuity or the abortion language, they were reluctant to compromise on them. The Catholic Bishops Conference had just endorsed S. 1090 but were threatening to withdraw that support if the wording of the legislation were significantly altered—especially in regard to abortion. Denton finally had to compromise and eliminated the mentions of chastity and teenage promiscuity, but this did not prevent the liberal media, spurred on by groups such as the Alan Guttmacher Institute, from continuing to characterize this legislation as the "Chastity Bill." The abortion clause was also rewritten, after protracted negotiations, so that projects could still "provide referral

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for abortion counseling to a pregnant adolescent if such adolescent and the parents or guardians of such adolescent request such referral". Programs providing abortions were still ineligible for funding. Furthermore, the revision of the abortion clause reassured Senator Kennedy that entities such as the Johns Hopkins Program would continue to be eligible for funding.19 While the alterations in the language on chastity and promiscuity as well as the changes in the abortion restrictions met Kennedy's objections, they were not sufficient to garner support from many family planning activists, who continued to oppose the legislation because it focused on preventing premarital sex among adolescents. Representative Toby Moffet (D-CT) referred to the centers designed to reduce premarital sexual activity as "storefront chasity centers" and warned that "we'll be laughed out of every junior high school in America" (New York Times, July 29, 1981: 8). In addition, many liberals strongly opposed the clause that mandated, with only a few exceptions, parental notification if unemancipated minors were to receive any services. Yet because of changes in the bill and Senator Kennedy's willingness to cosponsor the revised legislation, most congressmen accepted it—especially because some saw this as a convenient bargaining chip for maintaining the Title X Family Planning Services Program as a categorical entity. The issue that evoked the least public controversy but had the most impact upon the direction and functioning of the new program was the compromise over the allocation of funds. By requiring that at least two-thirds of the fund be spent for demonstration services, Kennedy limited the research orientation of the legislation. In addition, by legislating that at least two-thirds of the services funds be used for care projects, Kennedy shifted the priorities of the legislation from the prevention of premarital sexual activity to the care of pregnant teenagers and young mothers. Furthermore, whereas from a demonstration and evaluation perspective any set of mandated core services for the care programs seriously limited the effectiveness of this program, Kennedy succeeded in requiring that all care demonstration projects provide the same basic set of core services. Although Denton had initially acceded to Kennedy's insistence upon the generous funding of the care projects and requiring a set of core services for them, when he fully realized the implications of

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that compromise he was distressed and tried unsuccessfully to renegotiate their agreement. He did obtain a clause that allowed the Secretary to revise the core services based on an evaluation of which services proved essential for helping young mothers and their children. While giving the Secretary the authority to revise the set of necessary core services for care projects seemed a reasonable way to overcome the restrictions introduced by Senator Kennedy, in practice this clause proved to be ineffective. Eunice Shriver succeeded in persuading Marjory Mecklenburg, the new Director of OAPP, not to alter the mandated set of core services. Thus, despite the fact that Senator Denton had envisioned the Adolescent Family Life Program as an innovative, demonstration program, in its first four years OAPP never really contemplated revising or even seriously evaluating the mandated core services. After reaching the agreement with Senator Kennedy, the Adolescent Family Life bill (S. 1090) was unanimously adopted by the Senate Committee on Labor and Human Resources on June 24, 1981, and authorized $30 million annually for three years. Although the bill quickly passed in the Senate, it enjoyed little active support in the House and Representative Waxman used it only to pressure the Senate to continue the Title X as a categorical program. Finally, during the hectic days of budget negotiation the Adolescent Family Life Program was passed because it was included in the massive Omnibus Budget Reconciliation Act of 1981, which set budget ceilings for all federal spending and was incorporated as Title XX of the Public Health Services Act (Washington Memo, August 14, 1981). The Senate-House Committee Conference added the Denton Bill to the massive reconciliation package because its supporters felt that its chances of passage were much better there than in the skeptical House—a procedure very reminiscent of the old Title VI legislation's enactment in the closing moments of the 95th Congress. Despite the seemingly large changes in the approaches to teenage pregnancy between 1975 and 1981, considerable continuities exist if one traces the evolution of the Office of Adolescent Pregnancy Programs (OAPP). Eunice Shriver and a coalition of advocates for federal programs for school-age mothers sought congressional assistance in 1975. Although they failed, they laid the

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groundwork for their success three-years-later. Senator Kennedy cleverly used the Carter Administration's initiative on teenage pregnancy, which was equally concerned about prevention and caring for young mothers, to enact the Title VI legislation, which under Lulu Mae Nix became a service program only for pregnant adolescents. Yet while the coalition succeeded in authorizing a sizable new domestic program, they failed to convince either the Congress or the White House of the need to provide adequate funding once the policymakers realized that prevention was no longer a major part of this legislation. The relative isolation and political weakness of the Adolescent Pregnancy Program was evident in 1980. Very few voices, inside or outside of Washington, protested the inclusion of the program in the Maternal and Child Health block grant as part of the Reagan Administration's reforms in federal programs. Whereas Kennedy's position in the Senate and influence in the Carter Administration in 1978 had been instrumental in enacting Title VI, the Republican takeover of the Senate and the election of Ronald Reagan seemed to doom his efforts to save the program. Yet Senator Kennedy once again displayed his political skills and legislative genius by latching on to Denton's proposed legislation to prevent premarital sexual activity among teenagers. Just as he had done three years earlier, Kennedy rewrote the proposed legislation so that at least two-thirds of the services funds had to be expended for pregnant teenagers and young mothers. He even managed to salvage the required core services for care programs despite questions on the efficacy of requiring that specific set of services for every project. As many conservatives had feared, Senator Kennedy's dream of a large-scale domestic federal program for school-age mothers stayed alive as a demonstration program, awaiting the return of a more favorable political climate. If the 1981 legislation saved care programs for teenagers, the Denton bill greatly expanded the nature and extent of their evaluation. Each care project was now required to undertake its own evaluation in conjunction with an educator from a college or university in their state. While the amount of money allocated for that evaluation was still quite small, given the expenses involved in such an undertaking, it at least emphasized the important role of evaluation in each of the projects. Furthermore, the new Title XX legisla-

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tion also made provisions for an overall, national evaluation, which presumably could overcome many of the limitations inherent in any local effort. The care portions of the new Title XX legislation looked remarkably similar to the earlier "School-Age Mother and Child Health Care Act" of 1975 and the "Adolescent Health, Services and Pregnancy Prevention and Care Act" of 1978. Yet the Denton bill also provided that up to one-third of all the funds could be used for research purposes. Although some opponents of the Title XX legislation feared that the research would simply duplicate the similar work at the Center for Population Research (CPR) of the National Institute for Child Health and Human Development (NICHD), in practice OAPP's research focused on new areas such as adoption, young fathers, child development, teenage marriages, and the role of the media, all relatively neglected by NICHD. Only about one-fourth of the funds could be used for the prevention of premarital sex among adolescents even though this originally had been the primary intent of Senator Denton's efforts. While the compromises with Senator Kennedy and the money allocated for research reduced the total amount of funds available for prevention, this aspect of the legislation evoked the most public attention and frequently elicited derision from those who did not believe that the large increases in adolescent sexual activity during the 1970s could be reversed. While most policymakers in 1975 and 1978 debated the relative allocation of federal funds between family planning services and care for pregnant teenagers, Denton succeeded in introducing another dimension to the discussions—the prevention of premarital sexual activity altogether. Thus, although there is remarkable continuity between elements of the Title VI and Title XX legislation, the new emphasis on preventing premarital sexual activity nicely illustrates the recent political changes in the Congress and the White House in 1981, which have considerably broadened discussions about teenage pregnancy.

4 The Parental Notification Controversy

On February 22, 1982, the Department of Health and Human Services (DHHS) proposed regulations (U.S., Federal Register, Feb. 22, 1982: 7699-7701) that would have required parents of patients under age eighteen to be notified whenever a Title X funded family planning clinic provided prescription contraceptives to their child. The parental notification regulations were among the most important initiatives of the Reagan Administration in the area of adolescent pregnancy and provoked widespread controversy throughout the nation. Over 120,000 individuals commented on the regulations—one of the largest number of responses to any DHHS proposal. These regulations also shaped, to a larger degree than anticipated by the participants, the actions and fate of the Office of Population Affairs (OPA) and the Office of Adolescent Pregnancy Programs (OAPP) under Marjory Mecklenburg. While much has been written about the proposed parental notification regulations by its supporters or opponents, the issue has not been analyzed from a broader historical and policy perspective. Particularly lacking is a discussion of why and how the Reagan administration decided to make parental notification one of the cornerstones of its domestic social policy as well as an assessment of why it failed to make its case to the American people. Adolescents and the Legalization of Birth Control Americans began curtailing their fertility at least as early as the second half of the eighteenth century using traditional methods 87

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such as coitus interruptus (Vinovskis, 1981b). During the nineteenth century, American women increasingly used birth control, or in the last resort abortions, to limit their marital fertility (Mohr, 1978). While many women used birth control and abortion, many citizens opposed both as unnatural and undesirable. In the second half of the nineteenth century efforts to curb the flow of birth control information and devices as part of the crusade to eliminate vice were quite successful (Dienes, 1972; Reed, 1983). Anthony Comstock succeeded in securing the passage in 1873 of an "Act for the Suppression of Trade in, and Circulation of Obscene Literature and Articles of Immoral Use", which included a prohibition on the distribution of materials or articles for the prevention of contraception. Similar legislation soon followed in the states. This effectively stifled open public distribution of contraceptive information and devices for the rest of the nineteenth century. Birth control advocates such as Mary Ware Dennett and Margaret Sanger challenged the anti-contraceptive laws in the early twentieth century (Gordon, 1976; Kennedy, 1970). They labeled these laws unfair and discriminatory because middle-class women could continue to obtain contraceptives covertly from their private physicians while poor women were denied access to them. Gradually, and often after considerable controversy, the prohibition against the distribution of contraceptives eased as the courts exempted physicians from the ban. Some privately funded family planning clinics were established in the 1920s and by 1930, fifty-five family planning clinics had been set up in twelve states (Lader, 1955). The arguments in favor of the legalization of birth control almost always addressed the need for family planning by married adult women while the arguments against any changes frequently stressed that unmarried women would use these devices to lead an immoral life. Almost no one paid attention to the needs of sexually active unmarried teenagers as few reformers were willing to defend publicly the adolescents' right to birth control information and devices. By the early 1960s a more favorable climate existed for the legalization of contraceptives. There was a widespread public acceptance of contraceptives and the use of them by adult married women despite the continued opposition of the Catholic Church (Pomeroy and Landman, 1972). In addition, the federal government slowly and quietly began supporting family planning activi-

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ties abroad through the State Department and the Agency for International Development (AID). As part of the war on poverty, the Office of Economic Opportunity (OEO) financed more than a dozen family planning projects for indigent married women in the United States by late 1965.1 The courts played a very important role in the liberalization of access to contraceptives (Dienes, 1972). Legislatures were often reluctant to repeal laws prohibiting the distribution of contraceptives even though there was usually no real attempt to enforce the statutes. The federal courts, however, willingly intervened. In Griswold v. Connecticut (381 U.S. 479 (1965)), the Supreme Court declared the Connecticut law against the use of contraceptives unconstitutional and proclaimed a new marital "right of privacy." While some legislatures quickly tried to limit the scope of the ruling by passing new laws against the distribution of contraceptives to unmarried women, the Supreme Court in Eisenstadt v. Baird (405 U.S. 438 (1972)) held that the Massachusetts prohibition against the distribution of contraceptives except to married persons violated the rights of single persons under the Equal Protection Clause of the Fourteenth Amendment. Thus, the Supreme Court legalized the use and distribution of contraceptives although it had not clarified what access minors had to family planning services. By 1972 the federal government supported domestic family planning services under four different statutes (Center for Family Planning and Program Development, 1974): 1. Title X of the Public Health Service Act 2. Title IV-A of the Social Security Act 3. Title V of the Social Security Act 4. Title II of the Economic Opportunity Act, and the Emergency Employment Act of 1971

Although the specific targets of these programs varied somewhat, minors were not excluded from participation. During the hearings on these laws, however, family planning advocates remained uniformly silent on the needs or the eligibility of minors to receive these services.2 When Alan Guttmacher, the President of Planned Parenthood, for example, was questioned at the Title X

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hearings about adolescents attending family planning clinics, he quickly assured the congressmen that private rather than government funds paid for these services (U.S., Congress, House Committee on Interstate and Foreign Commerce, 1970: 285–286). As a result of the Supreme Court decisions and the reactions by the state legislatures in the early 1970s, minors could obtain and use contraceptives. However, teenagers still often had to inform their parents in order to receive these services. In the case of prescription contraceptives, some states even required parental permission. The growing acknowledgment of the problems of adolescent pregnancy as well as the general liberalization of birth control led to efforts to allow minors to receive prescription contraceptives from physicians without parental consent. The Executive Board of the American College of Obstetricians (ACOG), for example, recommended in 1971 that: These restricting legal barriers should be removed even in the case of an unemancipated minor who refuses to involve her parents. A pregnancy should not be the price she has to pay for conception. On the other hand, in counseling the patient, all possible efforts should be made to involve her parents (quoted in Pilpel and Wechsler, 1971: 43).

The Commission on Population Growth and the American Future, established by President Richard Nixon and the 91st Congress, concluded that "it seems clear that the law also plays a role in the inadequate access of teenagers to contraceptive services. The laws here are not so much the laws on contraception, but the inchoate and never universally applicable common rule which has been considered to bar medical treatment and examination of minors without parental consent. . . ." Therefore, "we recommend that states adopt affirmative legislation which will permit minors to receive contraceptive and prophylactic information and services in appropriate settings to their needs and concerns" (Commission on Population Growth and the American Future, 1972: 99–100). Nevertheless, there was strong dissent within the Commission on Population Growth and the American Future on the issue of

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removing legal impediments for minors receiving family planning services. Representative John N. Erlenborn (R-IL) stated that: As to contraception, the law, and minors, I wish the Commission had applied an age qualification to the term minor. Even so, I cannot join the Commission's recommendation that all legal restrictions on access to contraceptive information and services should be eliminated to permit minors, youngsters under the age at which they are legally responsible for themselves, unlimited access to contraceptives and abortions. . . . By eliminating any need or concern for parental guidance, the Commission essentially takes the view that the child knows better than the parent what his rights and responsibilities are. This, in my view, goes too far in placing emphasis on individual right, and tends to ignore responsibility for one's own actions (Commission on Population Growth and the American Future, 1972:156).

Many congressmen and family planning advocates were still reluctant to discuss openly the plight of unmarried teenagers, but a growing sentiment dictated that something should be done to reduce the legal barriers that prevented adolescents from receiving family planning services.3 In addition, the general expansion of legal rights for teenagers during the early 1970s removed some of the legal difficulties to receiving contraceptive services. The adoption of the 26th Amendment in 1973, which permitted eighteenyear-olds to vote, for example, led to a reduction in the age of majority from twenty-one to eighteen in most states. The extension of the concept of emancipation, mature minor, and emergency services also increased the number of minors eligible to receive contraceptive services without parental involvement (Paul, Pilpel, and Wechsler, 1974). The Supreme Court continued to increase the rights of minors. In Carey v. Population Services International (431 U.S. 678 (1977)), the Supreme Court ruled that New York State could not deny minors the right to receive nonprescription contraceptives. Expanding upon its decision in Planned Parenthood of Central Missouri v. Danforth (428 U.S. 52 (1976)) against any blanket provision requiring the consent of parents for abortions for unmarried minors, it stated that:

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AN "EPIDEMIC" OF ADOLESCENT PREGNANCY? Since the State may not impose a blanket prohibition, or even a blanket requirement of parental consent, on the choice of a minor to terminate her pregnancy, the constitutionality of a blanket prohibition of the distribution of contraceptives to minors is a fortiori foreclosed. The State's interests in protection of the mental and physical health of the pregnant minor, and in protection of potential life are clearly more implicated by the abortion decision than by the decision to use a nonhazardous contraceptive.

The Supreme Court also ruled that hospitals, clinics, and private providers receiving federal funds either through Titles XIX or XX reimbursement or through Title IV-A (Aid to Families with Dependent Children), must provide contraceptive services for sexually active minors without regard to age, marital status, or parenthood and that such assistance precludes parental consent requirements (Jones v. T——H——, 425 U.S. 986 (1976)). These Supreme Court decisions not only expanded the access of minors to family planning services, but in effect nullified parental consent requirements on federal family planning programs. As a result, future efforts to mandate parental involvement focused on parental notification rather than parental consent clauses. Because the Supreme Court still has not ruled definitively on a parental notification or consultation requirement in the use of contraceptives by minors, legislators and administrators opposed to the liberalization of the contraceptive statutes and practices regarding minors have sought redress in this area.4 As discussed in Chapter Two, the Carter Administration and the 95th Congress initiated a full-scale effort to reduce adolescent pregnancies and help prevent teenagers and young mothers in 1978. An important part of this effort was convincing Congress that adolescents should be allowed access to family planning services without necessarily involving their parents. The House Select Committee on Population played a key role in 1978. The sixteen members represented a wide spectrum of views on population and abortion issues (including individuals such as Representative Erlenborn who had earlier strongly opposed the removal of any legal barriers for minors receiving contraceptive services) and were highly regarded by most other members of the House as the "experts" in this area.

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After extensive hearings on adolescent pregnancy, the Select Committee on Population unanimously approved language in its report that encouraged the expansion of the rights of minors to contraceptive services without informing their parents. One of the basic requirements for acceptable contraceptive services, especially with regard to teenagers, is confidentiality. Adolescents are frequently uncomfortable about their own sexual behavior and are threatened by the prospect that such behavior might be disclosed by the clinic, particularly to their parents. At the present time, however, almost half the States do not permit minors to consent to their own medical care, including family planning services; in these States, services to teenagers by family planning clinics require parental consent, thereby inhibiting teenage use of these facilities (U.S., Congress, House, Select Committee on Population, 1978b: 80).

In addition, the Select Committee on Population observed that: Certain laws and policies of family planning service providers also discourage—if not prohibit—teenagers from utilizing such services. If the Federal Government is truly committed to supporting teenagers who want to be sexually responsible, these counterproductive laws and policies should be reevaluated (U.S., Congress, House, Select Committee on Population, 1978b: 84).

The reauthorization of the Title X legislation in 1978 provided an important test of Congress's willingness to accept openly a more liberalized approach to providing minors with contraceptives.5 Representative Harold L. Volkmer (D-MO) offered the following amendment on the House floor to the Title X legislation, which would have required parental notification: No program or project which directly or indirectly receives funds under this title may prescribe or dispense any prescription drug or device used for birth control purposes, to an unemancipated child under the age of 16 unless the parent or guardian of such child is

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Representative Paul G. Rogers (D-FL), Chairman of the Subcommittee on Health and the Environment, provided a brief rebutal that incorporated the essence of the arguments against any parental notification requirement: I agree that family planning programs should encourage adolescents to discuss their sexual activities with their parents, but many simply will not come in if we require such a discussion. And what will happen to them? They risk becoming pregnant and we risk spending $4.5 billion a year in welfare costs for adolescent mothers and their dependent children (U.S., Congress, Congressional Record, October 13, 1978: 37044).

Volkmer's amendment was defeated ten to forty-five. Even more significant, it failed to attract enough supporters for a recorded roll call vote. Advocates of liberalized contraceptive services for minors expressed considerable concern that a roll call vote might have led to the passage of the Volkmer amendment. Yet even those congressmen who probably would have supported the Volkmer amendment on a recorded tally, preferred to allow the amendment to be defeated by not calling for a roll call vote.6 The Senate also reauthorized the Title X legislation without any parental notification provision and therefore the statute passed without that requirement. Thus, contrary to the expectations of many participants, parental notification was not enacted by either chamber despite the call for such a provision by some conservative and "pro-life" legislators and lobbyists. The Senate did, however, accept a parental notification requirement for the Adolescent Health, Services, and Pregnancy Prevention Act of 1978. Senator Jesse A. Helmes (R-NC) introduced the parental notification amendment: . . . no program or project which directly or indirectly receives funds under this title may prescribe or dispense any prescription contraceptive drug or device to an unemancipated child under the age of 16 unless the parent or guardian of this child is notified of the

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intent to prescribe or dispense such drugs or devices (U.S., Congress, Congressional Record, September 29, 1978: S16597).

Senator Edward M. Kennedy (D-MA) and the supporters of the bill were so anxious to have it enacted, that unlike their colleagues in the House, they readily acquiesed to the Helms amendment. Representatives Rogers and Scheuer insisted upon its removal in the House-Senate Conference Committee and the Senate sponsors of the legislation willingly accommodated them.7 Parental involvement became an issue again the next year when the House considered the Child Health and Assurance Act of 1979 (H.R. 4962 to amend Title XX of the Social Security Act), which was intended to strengthen and improve Medicaid services for low income children and pregnant women. Representative William F. Dannemeyer (R-CA) offered an amendment to recommit the bill to the Committee on Interstate and Foreign Commerce with the following instructions: . . . That, such services and supplies be made available to minors pursuant to this subsection shall only be provided upon the consent of the parent or legal guardian of said minor (U.S., Congress, Congressional Record, December 11, 1979: 35441).

Again, several representatives rose to speak against parental consent and the motion to recommit the bill with instructions was defeated 163 to 225. Because recommitting the bill to the Committee on Interstate and Foreign Commerce at this late date would have meant its demise in this session, one should not interpret the margin of the vote as an accurate indication of congressional opposition to the parental consent requirement. Nevertheless, the full House had reaffirmed twice in two years that it was opposed to adding either a parental notification or consent requirement to the provision of contraceptive services for minors. The Reagan Administration and the Proposal of a Parental Notification Requirement The election campaign of Ronald Reagan as President of the United States and the Republican capture of the Senate set the

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stage for a new challenge to the rights of minors to contraceptive services. At first, the Republicans attempted to put the Title X program into a block grant. When that failed, however, the Administration tried to mandate a parental notification requirement for unemancipated minors under age eighteen. This tactic would have prohibited minors from receiving prescriptive contraceptives from family planning clinics funded by the Title X program unless their parents were notified. As part of his overall attempt to reduce federal involvement and to increase the role of the states in the area of health services, President Reagan proposed that the Title X and about forty other categorical health programs be placed in a block grant.8 While the block grant idea had been initiated by President Lyndon Johnson in 1966, and pursued vigorously but unsuccessfully by President Nixon during his second term, the Reagan proposals were more ambitious and more likely to be enacted (Rosoff, 1981). Most conservative Republicans supported the President's proposals to block grant the federal health service programs. Fear persisted, however, among some that turning control of the family planning programs over to the states still would not eliminate perceived shortcomings in the present system, such as the provision of contraceptive services to minors without notifying their parents. Senator Jeremiah Denton (R-AL), for example, complained that the original purpose of the Title X program in 1970 had been subverted: The family planning program was originally designed to aid poor adults seeking assistance in planning the size of their families and spacing the number of their children. In recent years, many in the family planning community have changed this focus to teenagers, providing services and imparting values in the absence of their parents' knowledge, advice, and counsel and in contradiction of laws concerning sexual conduct in many of their own States. I have grave concerns that this new direction usurps parental prerogatives, hazards, and the health and wellbeing of the teenagers, and contributes to what I consider a very basic factor involved in our sociological problems, even national security problems: namely, the erosion of the institution of the fam-

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ily (U.S., Congress, Senate, Committee on Labor and Human Resources, 1981c: 73).

Senator Denton went on to say that he would not want to turn family planning funds over to the states without "some clarification of these issues" (U.S., Congress, Senate, Committee on Labor and Human Resources, 1981c: 73). Secretary of the Department of Health and Human Services (DHHS), Richard Schweiker, sympathesized with Senator Denton's observations but also reminded him that . . . under the block grant proposal, the family planning program did get the same treatment as other programs involved. They are put into the preventive health services block grant. So basically the preventive health services block grant would give the States the option of determining the characteristics, the nature, the purpose, and the objectives that will become more of a State matter under the proposal than a Federal matter (U.S., Congress, Senate, Committee on Labor and Human Resources, 1981c: 74).

Despite the reservations of some conservative Republicans about turning the control of family planning services entirely over to the states, they supported the Reagan Administration proposals and the Senate voted to place the Title X Family Planning Services Program in the preventive health block grant on June 25, 1981 (Washington Memo, July 3, 1981). The House, however, preserved the Title X legislation as a categorical health program. The Title X bill cleared the House Subcommittee on Health and the Environment by a narrow ten to nine vote (Washington Memo, June 5, 1981).9 After a series of difficult but fortuitous maneuvers, the House approved the Title X legislation on June 26 as part of a government-wide budget bill (Washington Memo, July 3, 1981). At the House-Senate Conference Committee on the budget reconciliation bill on July 28, Representative Henry Waxman (D-CA) succeeded in salvaging the Title X bill as a categorical program despite the vehement protests of Senators Orrin Hatch (R-UT) and Denton (Washington Memo, July 31, 1981). Sensing the likelihood of a defeat on the block granting of the Title X legislation, the Senate conferees explored ways of attaching a parental notifica-

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tion requirement to the bill.10 The senators failed, however, and the final Title X wording only states that: To the extent practical, entities which receive grants or contracts under this subsection shall encourage family participation in projects assisted under this subsection (P.L. 97–35).

This important subsection was to become the focus of the debate over the Reagan Administration proposal to require parental notification. The Conference Report on P.L. 97-35 further clarified the subsection as follows: The conferees believe that, while family involvement is not mandated, it is important that families participate in the activities authorized by this title as much as possible. It is the intent of the conferees that grantees will encourage participants in the Title X programs to include their families in counseling and involve them in decisions about services (U.S., Congress, House, Report No. 97-208).

At the same time, Senator Hatch requested that President Reagan, who had urged the Senate conferees to agree with the House position on Title X so the reconciliation bill could be enacted, provide him with a letter absolving Hatch of responsibility for compromising on that issue. The President complied and wrote Senator Hatch a letter on July 28 that stated: I regret that we do not have the votes to defeat the family planning program, and assuming that this is the best you can do under the circumstances, I reluctantly conclude that the best course is to enter into the proposed Conference agreement. Perhaps we can remedy some of the problems in the family planning program administratively during the next three years that it will remain as a categorical grant (U.S., Congress, House, Committee on Energy and Commerce, 1982:198).

Thus, the Title X Family Planning Services Program narrowly survived as a categorical program during the 1981 legislative session. Yet the frustration of the Reagan Administration and Senators Hatch and Denton over the lack of even a parental notification

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requirement in the final legislation led to efforts to rectify that situation within the DHHS—especially as the President had indicated to Senator Hatch that he would willingly support some administrative action. Many conservatives had long sought to reverse the growing access of minors to contraceptives. David Winston, a former top aide to Schweiker when the latter was a senator and now an active and influential participant in the Reagan Administration, had recommended on behalf of the Heritage Foundation that: The provision of prescriptive contraception services to unemancipated minors shall be conditioned upon the written notification to one or both parents or legal guardian of said minors. (Such notification to parents of the prescribing of contraceptive drugs and devices is consistent with the legal responsibility that parents have for the medical care of their children.) (Winston, 1981: 280).

This recommendation impressed some members of the Reagan Administration not only because it emanated from the Heritage Foundation, but also because Marjory Mecklenburg, one of the strongest proponents of the proposed parental notification requirement, was closely allied with Winston. In addition, Senator Denton had succeeded in enacting the Title XX Adolescent Family Life Bill, which required grantees to "notify the parents or guardian of any unemancipated minor requesting services from the applicant . . . and will obtain the permission of such parents or guardians with respect to the provision of such services" (Title XX, Section 22(A)). The inclusion and enactment of this parental consent requirement encouraged those who wanted to attach a similar clause to the Title X regulations (and later would be used by the Administration to justify its parental notification requirement). With the reauthorization of the Title X as a categorical program, the pressure from outside groups and Senators Hatch and Denton to add a parental notification requirement to the regulations mounted. Nevertheless, despite the appearance to outside observers of a united Reagan Administration, the issue had divided the political appointees and career bureaucrats within DHHS. The specific

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events leading to the decision to promulgate the parental notification requirements are not well known and will be considered here in some detail. The episode illuminates the intentions of the policymakers and can provide us with a glimpse of the way in which the federal government reaches decisions. Considerable speculation and uncertainty abounded concerning the views of DHHS Secretary Schweiker on the issue of parental notification. As a strong and consistent supporter of the Title X program in the past, some hoped that he would resist the growing political pressures to endorse a parental notification requirement. Yet recently and somewhat unexpectedly he had expressed opposition to the provision of prescriptive contraceptives for teenage parents under the Medicaid Program (New York Times, Jan. 30, 1981: A9). Therefore, most observers were uncertain as to how Schweiker would finally rule on the issue. Some political appointees and many career bureaucrats within DHHS opposed any Title X mandatory parental notification requirement. William J. White, the Director of the Office of Family Planning Programs, for example, continued to oppose any changes in the Title X program and he appeared to have the support of his immediate supervisor, Edward Martin, the Director of the Bureau of Community Health Services.11 Similarly, Edward N. Brandt, Jr., the Reagan appointee as the Assistant Secretary for Health, opposed a federal mandatory parental notification requirement. The Department of Health and Human Services (DHHS) had already initiated a general review and revision of the Title X guidelines as part of its normal updating of those regulations. DHHS was also considering its response to a suit brought against it by the state of Utah. Utah wanted to require parental consent for unemancipated minors receiving prescription birth control services from federally funded family planning clinics. The conservatives now sought to include a parental notification requirement as part of both those undertakings. Carl A. Anderson, Counselor to the Under Secretary of DHHS, distributed a memorandum on September 17, 1981, that cited President Reagan's letter of July 28 to Senator Hatch and made recommendations on a series of issues relating to the Title X program. Unlike many others in the Administration, Anderson called for a parental consent rather than parental notification clause:

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Consideration of the extent to which parental notification and consent procedures should be required in the provision of family planning services to unemancipated minors should be guided by factors concerning the health and safety needs of the child and the general welfare of the family. By regulation, this Department should set a minimum federal standard and allow states, in their own discretion, to provide for greater parental involvement. This minimum federal standard should require that each grantee obtain written parental consent for the provision of prescription birth control drugs or devices to an unemancipated minor as defined by state law. Such a standard would recognize that if a physician determined that physical injury might result to the child from such notification, the physician would still have the option to provide non-prescription contraceptives to the child without notification or consent of the parents (Anderson, 1981).12 Juan del Real, General Counsel of DHHS, responding to the Secretary's request for a policy in regard to Utah's suit, drafted a cautious memo a week later dealing only with the issue of whether states could impose a parental consent requirement on the provision of contraceptive services to unmarried minors. He observed that: Based on our review, we conclude that amending the regulations to permit states to make parental consent a condition of providing services to unmarried minors would be legally supportable. However, since any such amendment is likely to be challenged, you should be aware that the language and legislative history of Title X, as amended, also contain a sufficient basis for reaching the opposite conclusion. Thus, there would be some risk in amending Department regulations to permit the States to impose parental consent requirements in the Title X program (del Real, 1981a). Responding a few days later to the efforts to require mandatory parental notification from all Title X grantees, Juan del Real prepared a draft for a more general rule that only called for encouraging parental involvement: First, grantees would be required to encourage recipients of counseling services to involve family members, to the extent feasible and

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appropriate, in such counseling. Second, grantees would be required to encourage recipients of any other services to involve family members, to the extent feasible and appropriate, in decisions about these services. Third, where a project serves unemancipated minor, it would be required to comply with any state law requiring that notification be provided to or consent obtained from a minor's parent or guardian regarding the provision of family planning services to the minor (del Real, 1981b).

Particularly significant, from the point of view of the disagreements over the legislative meaning of the Title X bill, was his conclusion that mandatory parental notification was not intended by the Congress: With respect to the first two policies proposed above, it is our view that grantees should be given latitude to exercise discretion, judgement and sensitivity. A blanket requirement for consultation—one reading of the statute that the legislative history might suggest— would produce results which we believe that Congress did not intend . . . we do not believe that Congress intended projects to intrude upon the privacy of individuals seeking services or force them to choose between their privacy and access to services. Consequently, the proposed rules would leave projects sufficient flexibility to tailor the efforts made to involve the family to the recipient's desires and personal circumstances (del Real, 1981b).13

The drift of activities within DHHS seemed to be steadily moving away from any federal mandatory parental consent or notification requirement. Such an end would probably have been reached except for the persistent efforts of Marjory Mecklenburg. A relatively minor political appointee in DHHS, Mecklenburg had strong "prolife" credentials and was working closely on an informal basis with conservatives such as Senator Denton, Carl Anderson, and David Winston. Secretary Schweiker had specifically brought her into the Administration to help with the controversial issues of family planning, adolescent pregnancy, and abortion. Therefore, her views on parental notification carried considerable weight even among those who disagreed with her position.14 Because her immediate supervisor, Dr. Brandt, the Assistant

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Secretary for Health, did not favor a federal mandatory parental notification requirement, Mecklenburg had to tread carefully. She attacked the del Real memo of October 2 as "tentative in its implementation of the statutory amendment" and said that "other options should be considered" as well (Mecklenburg, 1981a). Mecklenburg suggested the other options that should also be presented to the Secretary: It would be possible for the Department to set a "Federal floor" for Title X projects that parental consent would be required before providing prescription contraceptives to unemancipated minors. It overcomes the length-of-time-to implement concern with the draft option, which stems from the fact that some legislatures only meet once every two years. Knowing your interest in providing States with the greatest flexibility, the definition of unemancipated minors could be left to State law. Of course, combining the third option of the draft NPRM with this option would provide even more for the States. If you want to give the States more flexibility, you could allow them to opt out of the "Federal floor" through State legislative action (Mecklenburg, 1981a).

Dr. Brandt, who opposed any mandatory federal parental notification provision, seemed interested in Mecklenburg's proposed "Federal floor", which implied considerable state control—especially because she only suggested expanding the options presented to the Secretary rather than settling on any particular recommendation at this stage. In addition, as a dedicated physician, Brandt liked Mecklenburg's other suggestion that projects need not insist on immediate notification or consent, if "clients indicate doing so would affect them adversely, if the project's medical director determines notification or consent would indeed be adverse. . . ." Instead, projects "would work with the minor to bring about family involvement and consent as soon as possible . . . " (Mecklenburg, 1981a). Therefore, Brandt suggested to del Real that the options being considered be expanded even though he personally continued to be supportive of del Real's approach. Mecklenburg's memorandum (1981a) and intervention succeeded in broadening the debate over the parental notification issue in DHHS by forcing its policymakers to accept mandatory federal

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parental notification as a viable option. The DHHS General Counsel continued to argue against a mandatory federal parental notification requirement, but now at least he acknowledged other options. Rejecting parental consent as not legally defensible, del Real reluctantly admitted that mandatory notification might be a viable alternative: Implementing "the extent practical" language by requiring the project director to condition services to any minor on family involvement unless the minor can show good cause for noninvolvement. The project director would be required to document why the minor's parents were not involved. We think this suggestion is marginally defensible. However, we think it is not as defensible as similar policy proposed in the draft NPRM, because it appears to raise a significantly higher barrier to access and thus to be challengable as inconsistent with the 1978 amendment. Moreover, we suspect that in practice the two policies should operate very similarly, in that projects that were determined to serve adolescents would aggressively find, and document, good cause. Therefore, the major difference between the two is likely to be their relative defensibility and the fact that this option would impose an additional recordkeeping burden on the projects (del Real, 1981c).

In discussing the parental consent option, the General Counsel also pointed out that some age limit would have to be designated (he did not explain why an age would not have to be selected for the parental notification option—perhaps because given his formulation of that alternative, any minor would be covered by the notification requirement). Yet he concluded that "the age chosen should be based on some data, and timing considerations do not permit the kind of investigation of the relevant professional literature that should be made to support the policy change" (del Real, 1981c). Mecklenburg continued to argue for her position and wrote a seven-page reaction to del Real's draft of the regulations on October 19. The tone of her memos became more assertive and confident and challenged the position of the General Counsel more directly. Her interpretation of the legislative intent of the Title X bills in 1978 and 1981 differed substantially from that of the General Counsel:

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The legislative intent on Title X in 1978 and 1981 plays a very important role in defining both the responsibilities and implications of what this Administration can do in the area of parental consent or notification for family planning services. My understanding of the legislative history of that bill generally agrees with your interpretation—though I think that we may have more of a legislative mandate to involve parents in this area as long as no unnecessary and insurmountable barriers are erected for adolescents receiving such services (Mecklenburg, 1981b). She then explored each of the alternative policies available. While faintly praising the option of letting the states set parental notification regulations as "this approach would be consistent with the Administration's efforts to allow the States, whenever possible, to develop their own policies and guidelines," she went on to characterize this approach as ineffective in practice: The disadvantage of this option is that it minimizes our ability to increase parental involvement. Left to themselves, most States and local family planning clinics have not and probably will not involve more parents. Despite the continued recommendations by the previous Congresses and Administrations on the need for more family involvement, it is estimated that only fifteen percent of adolescent parents received contraceptive services in 1978 from organized family planning programs which had any parental consent or notification requirements (Mecklenburg, 1981b). To bolster her case against leaving parental notification entirely to the states, Mecklenburg pointedly reminded everyone about the political considerations involved in this approach: Many outside individuals and groups will be deeply disappointed if this Administration fails to increase significantly parental involvement, and, since the 97th Congress specifically called for encouraging more family involvement, some legislators may feel that the Administration is abdicating its responsibility in this area by turning over all authority on this issue to the States (Mechlenburg, 1981b). Mecklenburg then returned to her favored position—setting a federal minimum for parental involvement whenever minors ob-

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tained prescription birth control services from family planning clinics but allowing states to maintain even more stringent regulations if they chose to do so. Particularly interesting in her discussion of this approach is her attempt to develop a health rationale for this approach: The advantage of this option is that it encourages family involvement by setting a minimum Federal standard while still allowing the States to develop and implement additional requirements which they deem are necessary. By focusing the Federal regulations on only prescription birth control methods, we would still reach the majority of teenagers receiving services from family planning clinics (approximately 83 percent of teenagers in these clinics are given prescriptive birth control methods). Since the potential health side effects of birth control pills and IUDs, especially for growing adolescents, are a serious concern for many physicians, public support and understanding for this option would be enhanced by this strategy. I also understand from GC staff that this option could also be supported legally by relying on the Secretary's general powers regarding health and safety issues (Mecklenburg, 1981b). Thus, the health issue surrounding the use of prescription birth control methods now received more attention and provided a preview of the Reagan Administration's emphasis on this topic in the final proposed parental notification regulations. The question of high teenage patient discontinuance rates at family planning clinics because parents and clinics could not remind adolescents of their scheduled appointments, which played a large role in the defense of the regulations later, was not mentioned or explored at this point. In addition, Mecklenburg acknowledged what her critics later pointed out, that parental notification did not necessarily mean increased parental involvement: A last thought I want to share is that it is important to realize that while parental awareness is an important and necessary precondition for parental involvement, it is not a substitute for it. We, at the program level, will have to strive to encourage Title X grantees not only to notify parents, but to develop specific programs to facilitate meaningful parental involvement either at the clinic or in the home.

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But given the realities of the present situation, it is difficult to see how the Title X director would actually get a substantial increase in parental involvement without mandatory Federal regulations which support such an effort (Mecklenburg, 1981b).

Mecklenburg then tried to answer the General Counsel's challenge to select an appropriate age for a federal "floor" for the parental notification requirement. Although DHHS devoted little time and attention to this issue within DHHS, it became one of the most important topics in the congressional and public debates over public notification. If one selected a very high age, such as eighteen or nineteen, almost every teenager would be covered by the proposed regulations, but most of the public would probably reject the proposal as unreasonable and unrealistic. On the other hand, if one chose a very young age such as fourteen or fifteen, public acceptance would be much higher, but the conservatives would undoubtedly complain that the Reagan Administration was sanctioning or encouraging sixteen- or seventeen-year-olds to receive prescription birth control services without involving their parents. Because Mecklenburg had some private reservations about the efficacy or political viability of a mandatory parental notification requirement and because her quick staff review of the child development literature pointed to significant differences between younger and older teenagers, she chose a low age as the basis for the proposed federal standard and cited the ages used by other respective conservatives as a means of justifying her recommendation: The "under 16" age standard which was in the Volkmer amendment could be considered as the floor. In 1979, about 4%, or approximately, 170,000 of the individuals served in organized family planning programs were under age 16. It probably is not necessary to bar consideration of "under 16" or any other Federal age standard just because the Volkmer proposal referred to age. Congressional history indicates a concern about a delay or barrier to services not about the specific age requirement. There are substantial differences from the Volkmer proposal available to us in other options, such as the time of notification and medical director exemption provision. If you want to provide more flexibility to States, you might also consider letting States apply for a waiver on the age provision if their circumstances warrant (Mecklenburg, 1981b).

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Following this exchange of memorandums, DHHS held a toplevel meeting in which Secretary Schweiker listened to the pros and cons of the various options. Though no decision was reached at that meeting on the final course of action, Schweiker clearly seemed to be leaning toward some form of mandatory parental notification. In discussing the options at that meeting, however, a very important development occurred that had far-reaching effects. The question of what the federal maximum age should be for parental notification was raised and one of the participants at that meeting, who opposed the mandatory parental notification option, casually suggested under eighteen. While Mecklenburg had recommended under sixteen in her previous memorandum (Mecklenburg, 1981b), she was reluctant to challenge the suggestion of a higher age. Therefore, the group accepted under eighteen at that meeting without any careful or detailed discussion about the implications of using that particular age. The selection of such a late age united the family planning community against the regulations. If Mecklenburg's original suggestion of under sixteen had been followed, it is likely that many more family planning advocates would have acquiesced to the new Administration initiative and that the debate over parental notification in the Congress and the news media would have been very different. Thus, the reluctance of the DHHS policymakers to appear too moderate by countering the casual suggestion that under eighteen be used as the federal standard with their own suggestion of under sixteen may have doomed the success of their proposal in the long-run. Secretary Schweiker asked that the various options available to him be drafted and presented for a final decision. The General Counsel reiterated his previous position: . . . our recommendation is that Department requirements adopted to implement the 1981 amendment be limited to requiring Title X grantees to encourage unemancipated minors seeking counseling, or other services, to involve their family, to the maximum extent possible, in these activities (U.S., Congress, House, Committee on Energy and Commerce, 1982: 224).

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The General Counsel again acknowledged that the mandatory federal parental notification requirement proposed by Mecklenburg might be legally defensible, but continued to oppose it anyway. His tone, however, became more supportive—perhaps because he realized that the Secretary was likely to select this option: Requiring parental notification when services (or at least prescription drugs and devices) are provided to any minor, unless the minor can show good cause for not involving the family. The grantee's medical director would be required to document why the minor's parents were not notified. We think this suggestion could be defended since the family involvement requirement is not absolute and could be described simply as a strong form of encouragement. However, we also believe that it could be challenged more easily than the policy proposed in the draft NPRM, because it appears to raise a higher barrier to access and thus could potentially be viewed as inconsistent with the 1978 amendment. Moreover, we suspect that in practice this option would differ little from that in the draft NPRM, in that grantees which were determined to serve adolescents would be likely to aggressively find, and document, good cause. Finally, this option would impose an extra record-keeping burden on grantees which would have to be approved by OMB (U.S., Congress, Committee on Energy and Commerce, 1982: 226).

The General Counsel memorandum also reflects the decision to use under age eighteen as the basis for the federal guidelines (U.S., Congress, House, Committee on Energy and Commerce, 1982: 225). Similarly, Mecklenburg's comments on the General Counsel's memorandum state that "the federal age floor could be 'under 18' which is the age of majority in most States" (U.S., Congress, House, Committee on Energy and Commerce, 1982: 231), but she continued to note that under sixteen could be used as specified in the 1978 Volkmer amendment. Thus, while the decision memorandums in early November generally related the previous positions of the participants, there was a significant and lasting shift on the age issue. Secretary Schweiker decided to go ahead with mandating parental notification for unemancipated minors under age eighteen who received prescription drugs or devices from Title X family planning

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clinics and the General Counsel drafted a revision of the family planning regulations on November 25. Dr. Brandt, who had opposed this approach, signed the document on Dec. 2, and the Secretary signed on December 21 (U.S., Congress, House, Committee on Energy and Commerce, 1982: 232–241).15 The proposed regulations were then discussed at a meeting of the White House Human Resources Cabinet on January 29, 1982. Some members of the Cabinet Council expressed surprise at the amount of money going into domestic family planning programs and wanted to take even stronger action than just requiring parental notification. They also realized that nothing had been done about the Title X program despite President Reagan's July 28 promise to Senator Hatch. Others, however, did not want the controversy over parental notification to keep the Administration from achieving its other goals and opposed any stronger measures. On February 8, 1982, Craig L. Fuller, on behalf of the White House, wrote Secretary Schweiker that parental notification had been discussed with the senior staff, but that further information was needed on four questions: 1. How much money, in total, does the Federal government spend on Family Planning Centers? How many Centers are there that use federal funds? Where are they? 2. How many individuals age seventeen and under use these centers for the purpose of receiving birth control prescriptions and devices? What is the age distribution? Ethnic distribution? Female distribution? 3. What is the rate of teenage pregnancy? Have the family planning centers been helpful in reducing this rate? Have they reduced the rate of venereal disease? 4. What form will the opposition take? On what grounds will they object? What are our responses (Fuller, 1982)?

The memorandum concluded: As the questions indicate, we want to have as much background information as possible. There is no objection with regard to giving the states authority to govern the family planning centers and the views expressed with regard to a Federal regulation requiring parental notification were generally favorable. However, I was asked to

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have you hold publication of the regulation until we have the requested background information (Fuller, 1982).

Secretary Schweiker responded to Fuller summarizing the Title X program, the major provisions of the proposed regulations, and the issue of congressional intent in this area (U.S., Congress, House, Committee on Energy and Commerce, 1982: 228-229). He also indicated why the Administration should not wait for more restrictive changes in the Title X legislation from the Congress: I carefully considered the alternative of foregoing any effort to end the present practice of providing prescription drugs and devices without parental consent or knowledge until Congress would act upon a legislative proposal to require parental consent in all States. I rejected this option because the proposed regulation is an immediate and major step toward restoring family involvement, and because the strong opposition of Democrats controlling the House committee of jurisdiction makes prospects for passage of parental consent legislation doubtful (U.S., Congress, Committee on Energy and Commerce, 1982: 229).

Although the White House might have had lingering doubts about the proposed parental notification regulations, Secretary Schweiker's public defense at the congressional hearings in the House on February 9, 1982, made it politically impossible to abandon the regulations (U.S., Congress, House, Committee on Energy and Commerce, 1982). In addition, the Secretary's cogent and reasonable presentation before Representative Waxman's generally hostile Subcommittee encouraged those who supported the proposed regulations. Finally, when President Reagan at his press conference on February 18 was asked about the effects of the proposed regulations on GIs under age eighteen in the armed forces, his response ended any Administration debates on the merits of this proposal: . . . I vetoed a bill that was contrary to what I believed while I was Governor of California, and that is for those who believe that the Government is interfering in the private lives of the young people by making such a requirement—those young people couldn't get their appendix taken out without their parents' permission—uh, a

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AN "EPIDEMIC" OF ADOLESCENT PREGNANCY? number of other things they wish the parents had—but I think the Government has no business injecting itself between parent and child in a family relationship and where it is very definitely a problem of concern to parents who are responsible for the children (New York Times, Feb. 19, 1982: A20–A21).

On February 22, 1982, the Department of Health and Human Services (DHHS) finally issued the long-awaited proposal to require parental notification for unemancipated minors under age eighteen (U.S., Federal Register, Feb. 22, 1982: 7699–7701): Under the proposed rules, projects would be required to notify the parents or guardian of an unemancipated minor where prescription drugs or devices were provided . . . At the same time, the proposed rule provides that notification need not precede the provision of services, but rather that it must occur after services are provided. . . . To effectuate the notification requirement, projects must verify that the notification was received. If projects are unable to verify that the notification was received, projects may not provide additional prescription drugs or devices to the minor. Also, projects must maintain records on the notifications and verification. In addition, the proposed rule provides that the minor must be informed about the notification requirement and permits an exception to the notification requirement where the project director finds that it would result in physical harm to the minor by a parent or guardian. The exception is meant to apply to cases where there is evidence of a history of child abuse, sexual abuse, or incest, or where there are other substantial grounds to determine that notification would result in physical harm to the minor by a parent or guardian. The exception does not apply to cases where notification would result in no more than disciplinary actions of an unsubstantial nature. . . . Finally, the proposed rule provides that the notification requirement shall not apply in cases where a project is providing prescription drugs for the treatment of venereal disease. This is consistent with the overriding public health necessity of ensuring prevention of infection of others. The proposed regulations also included, as anticipated, a requirement that Title X family planning clinics in states with more stringent laws had to obey the state regulations. As suggested by Carl

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Anderson (1981), the regulations also changed the definition of a "low income family" to reflect the income of the adolescent's family rather than his or her own personal income. "Since persons who are members of high income families receive services without charge, the present policy has the inappropriate effect of skewing the distribution of limited federal grant funds away from the patients who are the most financially needy" (U.S., Federal Register, Febr. 22, 1982: 7700). Thus, the Reagan Administration announced the proposed parental notification regulations and waited for the public reactions during the required sixty-day comment period. No one anticipated, however, the extent of the controversy that was to be unleashed by these proposed regulations. Reactions to the Parental Notification Proposal Family planning advocates knew that the Reagan Administration had been contemplating a parental notification requirement for teenagers attending federally funded family planning clinics. Although they did not have access to the internal debates on this issue, by the end of 1981 they had obtained some of the drafts of the proposed parental notification regulations.16 Led by the energetic but loosely coordinated efforts of the Alan Guttmacher Institute (AGI), the National Family Planning and Reproductive Health Association (NFPRHA), and the Planned Parenthood Federation of America (PPFA), opponents of the proposed family planning regulations mobilized support against the Administration's initiative.17 As expected, the defenders of Title X in the House led the attack on the proposed parental notification requirement. Representative Waxman spearheaded the effort in hearings before his Subcommittee on Health and the Environment (U.S., Congress, House, Committee on Energy and Commerce, 1982). He accused the Reagan Administration of blatantly ignoring congressional intent and recklessly jeopardizing the health of adolescents: . . . the administration acting as a law unto itself, is proposing to disregard its congressional instructions and to force family planning

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clinics to notify the parent of a teenage girl that she has come in, talked with a physician, and that the physician has made a recommendation and written a prescription. Such a proposal is a real barrier for many adolescents. The effect of such regulations would be to discourage an adolescent from coming into a clinic for counseling or contraceptive services and to set back the desired result of encouraging communication between the parent and the adolescent. Many teenage girls will simply not seek advice or assistance at all. The result will be more pregnancies among adolescents and more abortions. It is clear to me that these regulations are only the most recent step which the administration has taken in its ongoing war against family planning. Family planning clinics have been subjected to official harassment. The administration of the program has become deeply political. The program has been singled out for the most severe budget cuts (U.S., Congress, Committee on Energy and Commerce, 1982:147–148).

Waxman's accusations against the Administration were answered by his counterpart in the other chamber, Senator Denton, who defended the proposed family planning regulations as essential for preserving the rights of the family and well within the recently enacted Title X legislation: Parents of America should know that their adolescent children can go out this afternoon to a taxpayer-supported clinic, get powerful prescription birth control drugs and devices, and those parents will never know about it. Up until now, the federal government presumed that this was a proper policy. The proposed Title X rule to be discussed this morning, is a long overdue step towards re-establishing what are legitimate, parental rights. . . . It is my strong opinion that the language contained in the Conference Report of the Omnibus Reconciliation Act of 1981 does not, in any way, prohibit a regulation that would require grantees to notify parents within 10 days of providing prescription contraceptives to their adolescent children. Indeed, the explicit requirement in the Report that grantees "encourage participants in the Title X program to include their families in counseling and involve them in decisions about services" is a clear manifestation of Congress' general objec-

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tive to involve the parent (U.S., Congress, House, Committee on Energy and Commerce, 1982: 181, 184).

Overall, the opponents of the proposed regulations outnumbered the supporters in the 96th Congress—at least among those who felt strongly enough about the issue to take a public position on it. Nevertheless, the Reagan Administration was pleased that Secretary Schweiker had been able to defend the regulations effectively before the largely hostile House Subcommittee on Health and the Environment.18 Family planning advocates quickly mobilized prominent national organizations to oppose the Administration initiative. Among the many national organizations speaking against the proposed DHHS regulations were the American Academy of Pediatrics, the American Bar Association, the American Civil Liberties Union, the American Medical Association, the American Public Health Association, the Children's Defense Fund, the Girls Clubs of America, the National Organization for Women, the National Urban League, and Zero Population Growth (Kenney, Forrest, and Torres, 1982). The National Urban League, for example, opposed the regulations because: Taken together, these statistics indicate that this rule will have distinct and disproportionate consequences for black youth. More than any other group, they will be the victims of this attempt to legislate morality. Yet the effort is clearly futile and ultimately harmful to our young people. Advising teenagers that their parents will be informed of their activities will only serve to prevent them from seeking assistance. Although the goal of encouraging greater communication is commendable, encouragement is all the government can offer, and all that the Congress has mandated.

Compared to the groups opposing the proposed regulations, supporters were fewer in number and much less active. Their comments on the proposed regulations tended to be short and not as detailed as those of opposition organizations. Major organizations supporting the DHHS regulations included the American Citizens Concerned for Life, the American Life Lobby, the Lutherans for

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Life, the Moral Majority, the National Conference of Catholic Bishops, the National Conference of Catholic Charities, and the United Families of America (Kenney, Forrest, and Torres, 1982). The National Conference of Catholic Charities, for example, endorsed the proposed regulations on behalf of its membership organizations in 152 dioceses throughout the United States: We at the National Conference of Catholic Charities are most supportive of the published announcement of the proposed rule to encourage family participation in the provision of contraceptive services to minors, particularly those drugs and devices that are issued by prescription only. They may be a threat to the future well being of the child being treated and the family certainly should be aware of their use, except as indicated in the regulations where the danger of family involvement would be a more immediate physical danger than the use of the prescription device or drug. But even more, we are concerned about any intervention by an outside agency that interferes with the relationship between a child and his or her parents. The federal and state governments and voluntary organizations have rightly been criticized in the past for providing services in such a way that they interfere with the normal responsibility of parents. When the family is in the position to need help in providing necessary services, they should be provided with family participation (National Conference of Catholic Charities, 1982).

Scholars interested in adolescent pregnancy usually objected to the proposed regulations. The academic community countered publically with findings from studies that tried to demonstrate that family planning clinics already involved parents (Furstenberg, Herceg-Baron, Mann, and Shea, 1982), that increased parental involvement did not necessarily reduce adolescent sexuality or improve contraceptive use (Herceg-Baron, and Furstenberg, 1982), and that a parental notification requirement would lead to a large increase in adolescent pregnancies and abortions (Torres, Forrest, and Eisman, 1980). The Administration managed to assemble some academic expertise during this controversy by drawing on personnel from the Office of Population Affairs (OPA). These scholars were able to interpret and critique studies cited by the opposition, but because many personally opposed the pro-

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posed regulations, the Administration was afraid to use them when challenging such studies before the news media or at scholarly meetings.19 Throughout the debate over parental notification, the Reagan Administration frequently used the studies of its opponents to support its own case. DHHS cited portions of the AGI analysis (Torres, Forrest, and Eisman, 1981) on the impact of a parental notification requirement to demonstrate that some adolescents would cease being sexually active and that few would stop using contraceptives altogether. The earlier work of Frank Furstenberg (1976) on black adolescent mothers in Baltimore was used to argue that parental involvement improved contraceptive use. Similarly, a recent study (Ager, Shea, and Agronow, 1982) of adolescents discontinuing their visits to family planning clinics was quoted to support the notion that the perceived medical risks associated with using prescription methods of contraception discouraged many teenage patients from returning to family planning clinics for services. The DHHS made the decision to draft a parental notification regulation without carrying out a careful review and analysis of relevant scholarly studies on this issue. Only after DHHS had reached the decision to go ahead with the regulations did it undertake a serious effort to consider the relevant secondary literature in preparing for the anticipated hostility to the Administration's initiative among the experts. As a result, while DHHS tried to quote accurately from the social science studies it cited, it only used findings to bolster a predetermined position. Not surprisingly, several of the scholars quoted by DHHS complained that their works were being cited out of context in support of mandatory parental notification.20 Overall, the Reagan Administration succeeded in at least blunting the seemingly unified academic opposition to the proposed regulations at the congressional hearings (U.S., Congress, House, Committee on Energy and Commerce, 1982) and in its written responses to the public comments on this measure (U.S., Federal Register, Jan. 26, 1983: 3600-3614). Yet the Administration ultimately failed to cast any serious doubts on the validity of the scholarly studies cited in opposition to the proposed DHHS regulations. As a result, most observers felt that the Administration was supporting the proposed regulations despite the overwhelming and

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seemingly impeccable scholarly evidence that notification would provide very few tangible benefits while greatly increasing the number of adolescent pregnancies and abortions. Most of the national press strongly denounced the proposed parental notification requirements. The opponents of the regulations effectively convinced reporters and editors that the regulations would lead to more teenage pregnancies and abortions. One of the most effective strategies was to label the regulations "the Squeal Rule", a pejorative label that the Reagan Administration was never able to overcome.21 A New York Times editorial titled, "What the Squeal Rule Will Breed", observed that: Rather than reduce the number of teenage pregnancies and abortions, the new ruling will probably raise both. Yes, it may bring a few more parents "into the picture," but it's sure to drive thousands of teenagers out of the agencies. That prospect does not appear to disturb Miss Mecklenburg. "We are not trying to keep the attendance at clinics up," she said in a recent interview. Why not? Isn't that Miss Mecklenburg's job—to carry out Congress's intent to reach teenagers and prevent teen-age pregnancy? What Miss Mecklenburg seems to be saying is that anyone old enough to be sexually active is old enough to shift for herself—and never mind the consequences for herself, her child and the welfare rolls (New York Times, April 16, 1982: A30).

The Los Angeles Times joined the attack on the proposed regulations under the editorial headline of "Secrecy Beats Pregnancy": Proponents of the "snitch" regulation contend that involving parents in the problem of teen-age birth control would be effective. We, too, would like to see such parental involvement. Sexually active teen-agers keep such activity from their parents. If they know their parents will be notified they will not stop their sexual activity. And that could only mean more unwed mothers, abortions, school dropouts, welfare dependencies, and heartaches (Los Angeles Times, April 21, 1982, II: 6).

The Chicago Tribune also condemned the Reagan Administration initiative in an editorial on "Sex, secrets, and Schweiker":

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Mr. Schweiker cannot turn back the sweeping social tides of sexuality with a single federal regulation. What he will do, if the regulation goes into effect, is undermine the efforts of family planning services to help minors use their sexuality responsibly to minimize its potentially disastrous consequences (Chicago Tribune, Feb. 28, 1982: 4).

A few more local and less well-known newspapers (Deseret News, April 16 to 17, 1982) did endorse the parental notification regulations, but overall the news media opposed the proposal. Initially, the Reagan Administration countered some of the attacks by dispatching Marjory Mecklenburg to present arguments for parental notification on television news programs. But after a few weeks, opportunities for television appearances diminished and the Administration failed to make its case in the newspapers and weekly news magazines. In part this failure reflects the decision within the Office of Population Affairs (OPA) to concentrate on preparing the legal documentation for parental notification instead of swaying public opinion. It also reflects the lack of an adequate staff within OPA to write news releases and to coordinate favorable publicity.22 DHHS's lack of interest and its inability to wage an aggressive public campaign on behalf of parental notification, coupled with the relatively inactive and ineffective support among outside organizations favoring the proposal, greatly handicapped the Reagan Administration's efforts to convince the public of the initiative's merits. The proposed parental notification requirement was issued on February 22, 1982, in the Federal Register and public comments were to be submitted by April 23. The total number of comments was unexpectedly large: approximately 60,000 individuals and 1,200 organizations (including family planning clinics, state and local governmental agencies, and national or local professional groups) wrote letters. Another 7,000 individuals responded by signing form letters and 10,000 to 20,000 individuals sent in postcards. Finally, several thousand individuals signed one of approximately 400 petitions (U.S., Federal Register, Jan. 26, 1983:3601).23 The public response to the proposed regulations was overwhelmingly hostile—especially during the first weeks. One reporter (Wall

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Street Journal, April 2, 1982: 25) examined a sample of a 1,000 letters and concluded that eight out of ten comments opposed the regulations. Indeed, because so much of the mail opposed parental notification, the Office of Population Affairs (OPA) decided not to tabulate the results numerically and to deal only with the substantive arguments presented.24 In addition, the Reagan Administration encouraged organizations sympathetic to the regulations to solicit favorable letters and petitions, which helped somewhat to redress the imbalance of comments.25 Nevertheless, there is little doubt that the vast majority of those commenting opposed the proposed regulations. Although a large majority of those writing opposed parental notification because it would increase the number of teenage pregnancies, the general public remained more evenly divided on the results of such a regulation. According to a CBS News/New York Times Poll of March 11 to 15, 1982, of 1,545 adults, 32 percent felt that the proposed government regulations would result in more teenage pregnancies, 28 percent expected fewer pregnancies, and 32 percent said that they would remain the same (8 percent had no opinion).26 Parental Notification and the Courts After the period for public responses to the proposed regulations ended on April 23, 1982, the Office of Population Affairs (OPA) concentrated on processing and evaluating the comments. The individuals in the Administration working on these regulations simply assumed that the parental notification requirement would be enacted. Therefore, they concentrated on examining each of the comments in order to comply with the legal requirements while simultaneously preparing the strongest case possible for the anticipated legal suits against the proposed regulations. The process of examining the extraordinary number of comments generated by the proposed regulations was quite timeconsuming—especially given the limited number of OPA staff available for analyzing the responses. In addition, the Administration was in no hurry to promulgate regulations before the Novem-

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ber 1982 congressional elections as this might arouse further public antagonism against the Republicans. As a result, it was not until December that the DHHS leadership turned to revising the proposed parental notification requirements. Given the strong public hostility toward the proposed regulations, the Reagan Administration might have modified them in order to placate some of the critics and to appear more reasonable about public suggestions. Few teenagers, for example, use diaphragms as their method of birth control. Dropping the diaphragm from the proposed regulations would have exempted few adolescents while greatly bolstering the health rationale for the regulations as almost everyone agreed that adolescents using diaphragms experienced few negative health effects. Perhaps even more important for regaining public and media support but more controversial because so many teenagers were involved, would have been a change in the age of teenagers covered from under eighteen to under sixteen—the original suggestion by Mecklenburg and the one used by Representative Volker in his unsuccesful amendment to the Title X legislation in 1978. Other than making a few minor adjustments, such as detailing how notification was to be verified and stating that only one of the parents or guardians had to be notified, the final parental notification regulations closely resembled the original proposal (U.S., Federal Register, Jan. 26, 1983: 3600-3614). Although DHHS did discuss the need for some positive response to the criticisms, it finally decided to stay with the regulations as originally drafted. The Administration had already endured the political attacks of liberals; it did not want to antagonize the conservatives as well by retreating from its initial position. In the end, the Administration paid relatively little attention to the merits of specific objections to its plan because its final decision rested on an overall endorsement of the principle of involving parents and an assessment of the political risks; the Administration did not carefully consider the overall impact of the new requirement on adolescents.27 One day prior to making his forthcoming resignation public, Secretary Richard Schweiker announced his decision to issue the final regulations pending clearance from the Office of Management and Budget (OMB).28 Some opponents to notification hoped that Con-

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gresswoman Margaret M. Heckler (R-MA), nominated to replace him, would try to stop or at least delay the regulations that she had previously opposed, but she did not. On January 26, 1983, (U.S., Federal Register: 3600-3614) the final regulations were issued and scheduled to go into effect February 25, 1983. As expected, several organizations challenged the parental notification regulations in the courts. Rather than filing a nationwide class action on behalf of all Title X providers, the opponents of the regulations agreed that several different challenges would be filed so that even if the government did win in one case, parental notification could not be immediately instituted nationally. Although injunctions to stop the implementation of the regulations were to be sought from several federal district judges, the two major cases were filed in the United States District Courts in the District of Columbia and New York. In the District of Columbia, the regulations were challenged by the Planned Parenthood Federation of America (PPFA) and the National Family Planning and Reproductive Health Association (NFPRHA). In New York they were opposed by the American Civil Liberties Union (ACLU), the State of New York, and the State Department of Health (Donovan, 1983).29 On February 14, 1983, Judge Henry C. Werker of the United States District Court in Manhattan issued a preliminary injunction against the regulations and extended it nationwide three days later (Donovan, 1983). In March the federal district judges in both Washington, D. C. and New York permanently blocked the implementation of the parental notification regulations solely on the basis that they violated the Title X law and congressional intent. As Judge Thomas A. Flannery of the U.S. District Court in Washington, D.C. wrote in granting the preliminary injunction: This court finds that such a review does lead it ineluctably to conclude that the regulations are unlawful, and that the plaintiffs are likely to succeed on the merits of their action. Turning first to the language of the statute itself, the court finds no grant of authority by Congress that reasonably contemplates the regulations promulgated by the Secretary (Planned Parenthood Fed. of America v. Schweiker, 559 F. Supp. 658, 667 (1983)).

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Nor did the judge find in the deliberations of the Conference Committee on the Title X legislation any justification for mandatory parental notification. Neither judge commented on the constitutionality of a parental notification requirement because both of them rejected the Administration's case simply on statutory grounds (Donovan, 1983). The judges in these cases also rejected the Administration's contention that the regulations would not be harmful to teenagers. Drawing upon the Alan Guttmacher study (Torres, Forrest, and Eisman, 1980) of the impact of a parental notification requirement, Judge Flannery concluded that "the regulations will deter minors from attending family planning clinics and thereby increase their risk of pregnancy" (Planned Parenthood Federation of America v. Schweiker, 559 F. Supp 658, 663 (1983)). The Administration appealed these judgments and tried to bolster its weak congressional intent argument by asserting, that the parental notification requirement in the Title XX Adolescent Family Life legislation demonstrated that the 97th Congress intended to change the Title X program in the same direction. The lawyers for the plaintiffs strongly disagreed and pointed out that the Title XX and Title X bills were quite separate from each other. The United States Court of Appeals for the District of Columbia Circuit agreed with the plaintiffs when it ruled against the Administration on July 8, 1983: This court is, of course, fully aware that these Title X regulations are at the center of a great whirlwind of public controversy. No doubt the moral and political wisdom of the Secretary's actions will remain in dispute for some time to come. The legality of those actions, however, should not. Our review of Title X and its legislative history leads to the inescapable conclusion that the Secretary exceeded the bounds of statutory authority by promulgating regulations that contravene congressional intent (Planned Parenthood Fed. of America v. Heckler, 229 U.S. App. D.C. 336, 351 (1983)).

Similarly, the United States Court of Appeals for the Second Circuit rejected the Administration's appeal on October 7, 1983, (State of N.Y. v. Heckler, 719, F.2d 1191 (1983)).

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Although the Department of Health and Human Services wanted to appeal these decisions to the Supreme Court, the lawyers in the Justice Department recognized their weak position and persuaded the White House to drop the parental notification case. While the Reagan Administration nursed some hope that the Congress might attach regulations to the Title X legislation, most observers noted that parental notification would probably not be mandated in the near future. Conclusion The provision of federally funded family planning services for adolescents is a relatively recent phenomenon in our history. Twenty years ago, family planning providers and policymakers were reluctant to acknowledge publicly that teens even had access to such services. Yet today the provision of contraceptives to teenagers, even without their parents' knowledge, seems commonplace and normal to many Americans. Several factors contributed to this change. For example, the steady expansion in government provision of contraceptives to all women has led to a greater tolerance for the provision of contraceptives to unmarried teenagers. A few outspoken individuals still oppose any government participation in the distribution of contraceptives, but most Americans today see federal involvement as not only acceptable, but an important government service. Indeed, even many congressmen critical of the current Title X legislation want only to return the control of the program to states and local governments. As a result, the idea that government should fund contraceptives for unmarried teenagers seems less controversial now because most of us accept and expect federal involvement in providing family planning services for women. Strong, negative views of premarital sexual activity were more characteristic of the 1950s than of the 1960s and 1970s. As our society becomes increasingly tolerant of premarital sexual activity, providing contraceptives to unmarried teenagers becomes more acceptable. In fact, premarital activity among teenagers had become so pervasive that many now accept it as inevitable and focus only on ways of encouraging sexually active adolescents to use contracep-

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tives effectively. A vocal minority still protests the sexual permissiveness of our society, but the majority of Americans no longer condemn everyone who engages in premarital sexual activity. Historically, few have challenged the rights of parents to oversee the behavior of their own children—especially in regard to their sexual development. Only when parents failed to supervise the activities of their children properly was it considered necessary for the church, the schools, or the state to intervene. Colonial and nineteenth-century Americans would have been astonished at the suggestion that unmarried adolescent children should have a right to privacy or contraceptive use. Yet in the 1960s and 1970s a growing contingent acknowledged the rights of children independent of their parents. The rights of unemancipated minors have expanded while parental control over them has contracted. Certainly one of the most important developments that made parental consent or notification seem unwise was the growing concern among the public and policymakers over the "epidemic" of adolescent pregnancy during the 1970s and 1980s. As we have seen in Chapter Two, the "epidemic" nature of adolescent pregnancy was exaggerated. Nonetheless, the emergence of adolescent pregnancy as a major domestic problem in the second-half of the 1970s provided an environment conducive to the restriction of parental rights and responsibilities as a means of reducing adolescent pregnancies and abortions. For many adults, concern about curtailing the "epidemic" of adolescent pregnancy took precedence over their desire to involve parents in the contraceptive decisions of their children. Public opinion polls have shown American adults to be rather evenly split on the wisdom and efficacy of a parental notification requirement. Yet the media and public outcry against the regulations were much more one-sided. In part this reflects the fact that since the late 1960s the number of individuals providing contraceptive services through federally funded family planning programs has increased. As a result, opponents easily alerted and mobilized professionals and volunteers working in these clinics to oppose regulations that they believed would be injurious to their clients. In addition, the great increase in domestic family planning programs during the past twenty years either created or helped to sustain powerful new advocacy organizations (such as AGI, PPFA,

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and NFPRHA), which played an important part in defeating the Reagan Administration's parental notification regulations. Thus, the development of a domestic family planning profession with its own organizations provided the institutional basis necessary to combat the proposed Title X regulations. Some of the improvements in the availability of contraceptives for unmarried teenagers are a result of judicial decision in which the courts reaffirmed or even expanded the access of adolescents to federally funded family planning services. The courts often protected unmarried adolescents seeking family planning services from barriers erected by state or federal legislators. The rejection of parental consent for unemancipated minors receiving birth control information and devices, for example, came from the courts, not the legislatures. Many Americans, especially those who experienced their own teenage years before the 1970s and 1980s, were surprised to discover that emancipated minors could now receive prescription birth control devices from federally funded family planning clinics without their parents' consent or knowledge. The Reagan Administration was determined to reverse this erosion of parental responsibility and authority through the proposed Title X parental notification requirement. This effort forced everyone involved to confront publically the gradual changes of the past two decades. The strong media opposition, the overwhelming hostility of the public, and the rejection in the federal courts of the proposed regulations has seemingly acknowledged and ratified the gradual and quiet evolution of confidential adolescent access to contraceptive services in family planning clinics. Given the importance of the proposed Title X regulations for defining the parameters of parent-child relationships in this highly controversial area, perhaps the Administration would have been wiser to adopt the lower age for notification suggested by Mecklenburg. This might have fostered the clear establishment with considerable public support of the precedent that parents have a right and responsibility to be involved in the contraceptive decisions of their young adolescent children. Instead, the Administration, without too much deliberation, arbitrarily selected a much higher age for parental notification, which immediately solidified the opposition against its proposal and had the unintended effect of further eroding parental rights by publiciz-

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ing the earlier changes and stimulating almost unanimous opposition from the media and the experts in this field. By inadvertently choosing to fight the principle of parental notification under such adverse circumstances, the Reagan Administration may have seriously weakened the support from conservatives in the Congress and among the public who are still attempting to reverse the changes of the past twenty years. The parental notification controversy also had a major impact on the Reagan Administration's overall policies on domestic family planning. The Administration was committed to placing the Title X program into a block grant and thereby turning control of federal family planning funds over to the states. As a result, it made no effort to develop a detailed and comprehensive plan for administering the existing Title X Family Planning Program because, presumably, the program would be abolished by the Congress. Control of the Title X program remained under William White whom conservatives regarded as closely allied with the National Family Planning and Reproductive Health Association (NFPRHA) and the Planned Parenthood Federation of America (PPFA).30 Secretary Schweiker brought in Marjory Mecklenburg to oversee the Office of Adolescent Pregnancy Programs (OAPP). Although the appointment was regarded as a minor political position, he intended to consult her on issues of abortion and domestic family planning services as well as care programs for pregnant teenagers. She also replaced Ernest Peterson, a career civil servant, as the Acting Deputy Assistant Secretary for Population Affairs (DASPA) but did not have direct administrative control of the Title X program.31 Instead, she was expected to develop and comment upon family planning policies without the authority to implement her suggestions.32 As we have seen in Chapter Three, Mecklenburg was a moderate among the "pro-life" leaders who favored federal support of family planning. She accepted the Reagan Administration effort to place the Title X program into a block grant, but did not play a major role in that decision. If the Administration had wanted to end all federal involvement in providing contraceptives for adolescents and low income women, it could have appointed someone like Judie Brown, President of the American Life Lobby, an outspoken foe of all federal activities in this area. Thus, while the Reagan Administra-

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tion was committed to placing the Title X program into a block grant, it appeared willing to pursue a more moderate course than some conservative supporters had envisioned. With the failure of Congress to place the Title X program into a block grant, the Administration had to come up with a new plan. As pressure from conservatives mounted to oust White as the Director of the Office of Family Planning (OFP), the Administration relied more on Mecklenburg for policy advice. Some family planning service providers initially welcomed her apparent ascendancy; they hoped she would introduce reforms such as revising the formula for allocating Title X funds, encouraging family involvement when adolescents received clinic services, and upgrading the quality and usefulness of funds for research on service delivery improvements. Indeed, as the acting Deputy Assistant Secretary for Population Affairs (DASPA) Mecklenburg initiated several improvements in these areas, which encouraged some observers to think that the Reagan Administration might introduce some constructive improvements to the Title X program. The decision to require parental notification if anyone under eighteen received prescription contraceptives from a Title X clinic dramatically reduced the opportunities for the Administration to work together with family planning service providers toward improving other aspects of the program. The proposed parental notification requirement solidified hostility among almost all family planning providers against the Administration in general and Mecklenburg in particular, who seemed to be one of the chief architects of that initiative. Individuals within the family planning community who had urged cooperation between service providers and the Reagan Administration were now discredited by this proposal, and the opponents of the Administration rallied behind more hostile organizations such as NFPRHA. While the proposed parental notification requirement alienated most family planning service providers and their organizations from the Administration and Mecklenburg, it generated enthusiastic support from more conservative groups. Mecklenburg, who had once been opposed by the more conservative elements within the "pro-life" movement, was now embraced for her advocacy of parental rights and responsibilities. As groups like AGI, NFPRHA,

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and PPFA attacked Mecklenburg, her stature increased among conservatives both inside and outside of the Administration. One of the immediate benefits of Mecklenburg's new public visibility and support among conservatives was her enhanced position and power within the Department of Health and Human Services (DHHS). Prior to the parental notification crisis most DHHS policymakers and bureaucrats regarded her as a minor political appointee and paid little attention to her requests and ideas. After she succeeded in defeating both the DHHS General Counsel and the Assistant Secretary for Health on the parental notification issue, others came to view her as a powerful and ambitious individual with ready access to the Secretary as well as important senators like Denton and Hatch. Indeed, she succeeded in not only replacing White as the Director of the Office of Family Planning (OFP), but also in having that unit placed under her direct control as the DASPA—something that family planning supporters had failed to achieve during the past decade but opposed once Mecklenburg filled that post.33 If Mecklenburg increased her standing within DHHS and among conservatives by her role in the parental notification controversy, she simultaneously undermined her position among family planning service providers and their supporters. She became the symbol of the Administration's assault on the existing system of family planning programs and the primary target of those opposed to parental notification. Organizations like NFPRHA also attacked her because she tried to terminate their federal funding as part of her attempt to redirect the service delivery improvement money into applied social science research.34 Opponents of Mecklenburg attacked her through their congressional allies in the House like Representative Silvio Conte (R-MA), and some even carried out a concerted campaign against her personal life. The parental notification battle consumed a tremendous amount of staff energy and time at DHHS. The Department set aside other important reforms and improvements in the Title X Family Planning Program or the Title XX Adolescent Family Life Program in order to cope with the unexpected avalanche of public comments and negative media coverage. In effect, the decision to go ahead with the parental notification regulations precluded working seri-

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ously on many other issues during much of Mecklenburg's tenure as the director of both the Title X and Title XX programs. Overall, the parental notification issue deepened the hostility between the Reagan Administration and the Title X family planning service providers and their allies. While the controversy made Mecklenburg a more important and powerful appointee within DHHS, thereby helping her to achieve some of her program goals, it also unleashed personal and professional attacks, which eventually led to her resignation in 1985.

5 Reassessing the Impact of a Parental Notification Requirement: Some Conceptual and Methodological Observations

Occasionally the results of a particular study become a focal point during policy debates. In the discussions over the advisability of busing students in order to desegregate public schools, the Coleman Report (Mosteller and Moynihan, 1972) was used by both sides. Similarly, in the controversy over the black family, the Moynihan Report (Rainwater and Yancey, 1967) was central to the debates. During the controversy over the proposed regulations to require that parents or guardians be notified whenever unemancipated minors under age eighteen received any prescription method of birth control from a family planning clinic supported by Title X funds, the study by Torres, Forrest, and Eisman (1980) of the Alan Guttmacher Institute became the reference for anyone estimating the effects of these regulations. Although the Torres' group had completed its study several years before the present regulations were proposed in the Federal Register on Feb. 22, 1982 (DHHS, 1982), it was used almost exclusively for assessing the impact of those regulations. In fact, almost all the indepth criticisms (AGI, 1982; NFPHRA, 1982; PPFA, 1982) relied on this study to argue that nearly one-quarter of the 131

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adolescent patients at family planning clinics would stop going there if their parents had to be informed. The Reagan Administration (U.S., Congress, House, Committee on Energy and Commerce, 1982), on the other hand, relied on the same study but cited the fact that only 4 percent of the adolescents at those clinics said they would stop using contraceptives but continue to be sexually active if they had to notify their parents. Thus, though the opponents and supporters of the proposed regulations emphasized different aspects of the Torres et al. study (1980), they all agreed upon its centrality and relevance to the current debate over parental notification. Despite the importance and prominence of the Torres et al. study (1980), no one has thoroughly reexamined its methodology or its applicability to the proposed Title X regulations on parental notification. In fact, most individuals who continue to cite this essay are unaware of the authors' 1982 revisions (AGI, 1982). This analysis will review the conceptual and methodological aspects of that study, revise and update its findings using data that have become available since 1980, and examine its relevance to the proposed Title X parental notification requirements.1 The reconsideration of the Torres et al. study (1980) will also allow us to explore the use of social science research in policy debates. Although in the previous chapter we briefly analyzed the use of social science studies in the parental notification controversy, we can now consider this topic in more detail by discussing not only the policy uses of the Alan Guttmacher Institute Study (Torres, Forrest, and Eisman, 1980), but also its scientific validity. Description of the Original Study The Torres et al. essay (1980) is based upon two different types of data: (1) a survey of parental consent and notification policies in family planning and abortion clinics and (2) a survey of unmarried teenagers under eighteen who had attended a family planning or abortion facility. Thus, four separate but related topics appear in the essay under the headings of "Abortion Provider Policies," "Family Planning Provider Policies," "Abortion and Parental Knowledge," and "Contraception and Parental Knowledge." As this chap-

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ter focuses on the analysis relating to the impact of the proposed Title X parental notification regulations on teenagers going to family planning clinics, it will concentrate on the data and findings found in the "Contraception and Parental Knowledge" section.2 The Torres et al. analysis (1980) relies on a self-administered questionnaire given at fifty-three family planning clinics between October 1979 and March 1980. The questionnaires were given to all teenage patients by the clinic staff during a two to four week survey period and yielded a 96 percent response rate. For their analysis, however, the researchers screened the sample to include only unmarried teenagers under eighteen. Altogether, the sample for this study was 1,241 unmarried women under eighteen—thirty of whom chose a nonmedical method of contraception and were subsequently omitted from the analysis as the focus was only on adolescents who had decided to use a medical method of contraception. The fifty-three family planning clinics included in this study were selected from the 1,150 hospitals, health departments, Planned Parenthood clinics, and other health facilities with 1,000 or more family planning patients in 1977. Though the survey of teenagers was based on less than one-fourth of the family planning clinics in the United States, those included represent about two-thirds of the women who received such services.3 Because the sample contains only teenagers going to facilities with relatively large caseloads, one might ask how representative it is of the experiences of all adolescents going to family planning clinics. Though the authors are quite explicit about their sample, most commentators who cite the study simply assume that it adequately represents all teenagers receiving family planning services from organized providers. Yet we should recognize that there may be some differences between small and large providers. Planned Parenthood clinics, for example, generally have a much larger caseload than other providers and therefore probably are over-represented in this sample. How this bias might affect the results is difficult to answer without more detailed information. On the one hand, because Planned Parenthood clinics are less likely to require parental notification or consent when unemancipated minors seek family planning services, the impact of any proposed mandatory parental notification regulations might be exaggerated. On the other hand, because Planned Parenthood af-

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filiates apparently have more extensive parental involvement programs than other programs (Furstenberg, Herceg-Baron, Mann, and Shea, 1982), the parents of these adolescents may already be aware of their daughter's participation and therefore teenage clients might be less likely to drop out if mandatory parental notification was required.4 The teenagers who had selected the pill, IUD, or diaphragm as their method of birth control were asked whether their parents knew of their visits to the clinics and what they would do if they could not obtain a prescription method "from this or any other clinic or doctor without your parent(s) being told." (Torres and Eisman, 1980).5 Most teenagers were either sure that their parents already knew (54.3 percent) or suspected that they may know (4.8 percent) (See figure 5–1). Another 18.2 percent thought that their parents did not know, but indicated that they were willing to come to the clinic even if their parents had to be notified. Finally, 21.2 percent of the adolescents did not think their parents knew they were coming to a family planning facility and would stop coming if their parents had to be informed. Of the 21.2 percent of the teenagers who say they would not continue to go to a family planning clinic if their parents had to be notified, most (69.3 percent) would switch to a nonmedical method of birth control such as the condom, spermicides, rhythm, or withdrawal (See figure 5-2). About one-fifth would continue to be sexually active, but would not use any contraception. Finally, nearly 10 percent say that they would stop being sexually active rather than have their parents notified. Torres, Forrest, and Eisman calculated the probable increase in pregnancies if a policy of mandatory parental notification was enacted using the estimate of 524,000 teenagers under eighteen who obtained contraceptive services from family planning agencies in 1978 and extrapolated the results from their survey of adolescents. For their figures on the risks of pregnancy for the different methods of birth control they relied upon estimates derived from the works of Zelnick and Kantner (1978a, 1980).6 They concluded that a policy of mandatory parental notification would be very harmful. About 125,000 adolescents would no longer come to the family planning clinics and 26,000 of these

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Source: Torres and Elsman (1980)

FIGURE 5-1. Percentage Distribution of Teenage Patients' Responses to the Question: "If You Couldn't Get a Method of Birth Control from This or Any Other Clinics or Doctor Without Your Parent(s) Being Told, What Would You Do?"

Source: Torres and Elsman (1980)

FIGURE 5-2. Percentage Distribution of Responses of Teenagers Who Would Not Go to a Family Planning Clinic if Their Parents Had To Be Notified

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FIGURE 5-3. Estimated Impact of Parental Notification Requirements on Contraceptive Practice and Pregnancy among Teenagers Ages Seventeen and Younger Now Attending Family Planning Clinics

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would continue to be sexually active without using any contraceptives. Altogether, they estimated that the requirement of parental notification would result in 33,000 additional adolescent pregnancies (see Figure 5-3).7 Some Conceptual and Methodological Considerations The original study (Torres, Forrest, and Eisman, 1980) estimated the impact of a parental notification requirement using a survey of teenagers in 1979-80 and data from 1978 on the number of teenagers attending family planning clinics. In the revised estimates (AGI, 1982), data on the number of teenage clients attending organized family planning clinics in 1979 (529,000) is substituted for the 1978 figure (524,000)—apparently because the 1979 data were unavailable at the time when the original article was drafted. Though the difference in the two numbers is quite small (about 1 percent), the 1979 data are more appropriate and will be used as the basis of my calculations as well (see figure 5–4A). The estimate of 529,000 teenagers under eighteen attending family planning clinics in 1979 who use medical methods of contraception includes married teenagers as well as those who already have had a child. Under the proposed regulations these adolescents are usually exempted from notifying their parents because under most state laws they would be considered emancipated. Among teenagers under eighteen going to family planning clinics, 14.1 percent were already mothers (AGI, 1982) and probably 4 percent were married—although some of the latter may have had a child as well and therefore overlap with the first category.8 We can reasonably estimate that 14 percent of teenagers attending clinics may be exempted from the proposed parental notification requirements because they are legally emancipated. Therefore, in the reestimate of the impact of a parental notification requirement, we need to subtract the 74,100 adolescents who may be legally emancipated and exempt from the proposed regulations—leaving 454,900 unemancipated adolescents ages seventeen or younger who attended a family planning clinic in 1979, received a prescription contraceptive, and would be affected by the proposed regulations. In estimating the number of teenagers whose parents already

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Source: Torres, Forrest, and Eisman (1980)

FIGURE 5–4A. Reestimated Impact of Parental Notification Requirements on Contraceptive Practice and Pregnancy among Teenagers Ages Seventeen and Younger Now Attending Family Planning Clinics know their children are coming to a family planning clinic (247,000) or those who would tell their parents if required to do so (101,000), the revised distribution of answers from the survey was used (AGI, 1982). Thus, using 1979 data, 106,900 adolescents said they would not return to the family planning clinic if they had to inform their parents of their visit. In studying the impact of a parental notification requirement on adolescents, the authors (Torres, Forrest, and Eisman, 1980) try to estimate what will happen to those teenagers during the next year. In other words, they follow the experiences of the cohort of

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unemancipated minors under eighteen who had received a prescription method from a family planning clinic in 1979 but would not return if they had to inform their parents. In using such an approach, the researchers should have taken into consideration the fact that some of these individuals would not be bound by the parental notification regulation for the entire twelve-month period because they would be turning eighteen during the course of that year. Thus, a girl who is seventeen and a half, for example, could simply wait six months before returning to the family planning clinic to obtain a prescription method. In calculating the risk of pregnancy due to her delayed use of a prescription method from the family planning clinic, we need to remember that the parental notification regulations put her at risk for six rather than twelve months. The reader might object, however, that as the seventeen-yearolds become eighteen, younger teenagers would have been entering the family planning clinic to replace them. Although it is true that additional teenagers will be coming into the clinic throughout the course of that year, the estimate by Torres et al. (1982) is intended to follow only the experiences of all the teenagers who came into the clinic in 1979 for one year. Those who enter the program thereafter during the course of the next year would become part of the analysis of the effects of the proposed regulations in 1980. The seventeen-year-olds make up 53.5 percent of the adolescents ages seventeen and under coming to family planning clinics (AGI, 1982). During the next year they will become eighteen at varying times and reduce the length of time by 50 percent that they will encounter any increased risk of pregnancy due to the proposed regulations. Thus, the aging of the seventeen-year-olds reduces the overall number of teenagers being adversely affected by the proposed regulations by 26.8 percent, from 106,900 to 78,300 adolescents at risk (see figure 5–4B).9 One of the problems in using the results of the Torres et al. study (1980) to assess the impact of the proposed Title X regulations is that the questionnaire assumed that any parental notification requirement would apply not only to family planning clinics but also to private physicians. As a result, the study did not consider the possibility provided in the Administration's proposal

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Source: (Torres, Forrest, Eisman, 1980).

FIGURE 5-4B. Reestimated Impact of Parental Notification Requirements on Contraceptive Practice and Pregnancy among Teenagers Now Attending Family Planning Clinics

that adolescents who did not want their parents to be notified might obtain a prescription method of birth control from a private physician instead. Many teenagers already go to private physicians for contraceptive services. Of the 2.7 million teenagers ages fifteen to nineteen who obtained family planning services from clinics or private physicians in 1979, 44.9 percent received them from a private physician (Torres, Forrest, and Eisman, 1981). In fact, private physicians are

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a prior source of assistance for 10 percent of the teenagers who use a medical method before coming to a family planning clinic (Torres, Forrest, and Eisman, 1980). Yet some of the teenagers coming to a clinic may be unable or reluctant to go to a private physician because of the higher cost or their fear that the doctor will notify their parents (Chamie, Eisman, Forrest, Orr, and Torres, 1982). Although the higher cost of a private physician will undoubtedly reduce the number of teens who may come, it will not deter all teens. In their survey of teenagers, Chamie and her associates found that about one-third did not even mention cost as a factor in choosing a clinic rather than a private physician (Chamie, Eisman, Forrest, Orr, and Torres, 1982). Furthermore, though the fear that the doctor might tell the parents was a concern for about one-fourth of the girls interviewed, this difficulty might be minimized in part by shopping around for a physician who does not insist that parents be informed. It is, of course, difficult to estimate what percentage of teenagers will turn to private physicians if they can not receive prescription methods of birth control from family planning clinics without their parents being informed. Undoubtedly many teenagers still will be unable or unwilling to go to a private physician. Yet among those unemancipated teenagers under eighteen who do not wish to tell their parents and still must face the prospect of becoming pregnant, it is likely that about 25 percent may go to a private physician. Although this figure may sound high, we should remember that those adolescents who have finally decided to go to a family planning clinic are probably more highly motivated than teenagers in general to avoid an unintended pregnancy.10 Altogether, an estimated 58,700 unemancipated teenagers under eighteen receiving a prescription method of birth control from family planning clinics in 1979 said they will not return to the clinic or go to a private physician. Instead, 30,200 will switch to a drug store method (such as condoms or spermicides), 9,700 will rely on rhythm or withdrawal, 13,300 will not use any method of contraception, and 5,500 will stop being sexually active. In order to calculate the additional pregnancies that may occur among the 58,700 adolescents who will not obtain a prescription method from a clinic if they had to tell their parents, it is necessary

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to know the risk of pregnancy for teenagers using contraceptives. Unfortunately, no satisfactory estimates are available on the risk of pregnancy for teenagers. As a result, researchers either rely on results that are methodologically suspect or utilize rates derived almost entirely from the experiences of married adults. The Torres et al. study (1980) made inferences about the risk of pregnancy for teenagers from two essays by Zelnik and Kantner (1978a; 1980). Torres and her colleagues estimated that 11.9 percent of teenagers using medical contraceptive methods would become pregnant; 34.1 percent of those using nonmedical methods would become pregnant; and 62.2 percent of those not using any method of contraception would become pregnant. The use of the data published by Zelnick and Kantner (1978a; 1980) for estimating the annual risk of pregnancy is unfortunate because this study did not specifically address that issue and only provided information on which teenagers had ever become pregnant. The period of time during which these teenagers had been sexually active varied considerably as did their consistency of contraceptive use, so the Zelnik and Kantner data as presented in the essays are conceptually and methodologically inappropriate for assessing relative risks even though the figures cited by Torres et al. (1980) may appear plausible. The inadequacy of their original estimate of the risk of adolescent pregnancy (Torres, Forrest, and Eisman, 1980) appears to be implicitly acknowledged in a subsequent essay by one of the original coauthors of that study (Forrest et al., 1981). Rather than relying on the results from the two Zelnik and Kantner articles (1979; 1980) Forrest utilized information on contraceptive failure rates among married women ages 15 to 44 based on the data from the National Survey of Family Growth (NSFG), Cycle II and analyzed by Grady et al. (1981). In addition, Forrest and her associates used data provided by Zabin et al. (1979) and Leridon (1977) to estimate the likelihood of a sexually active teenager becoming pregnant if she did not use any contraceptive method. Although the employment of contraceptive use failure rates among married women 15 to 44 is preferable to the inferences Torres and her associates (1980) made from the Zelnik and Kantner essays (1978a; 1980), the figures are still inadequate because these new rates are not based on low income teenagers—the indi-

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viduals most likely to need help from a family planning clinic as they cannot afford to go to a private physician. Fortunately, a study by Schirm et al. (1982) uses a multivariate life-table technique and data from the 1973 and 1976 NSFG, Cycle II to calculate first-year contraceptive use failure rates for married women under ages twenty-two with annual incomes less than $10,000. While even the Schirm et al. analysis (1982) is not entirely satisfactory for calculating the risk of pregnancy among unmarried, low income adolescents, it is considerably better than the original estimates by Torres et al. (1980). In fact, in its most recent comments on the risks of pregnancy for adolescents, the Alan Guttmacher Institute (1982) used the Schirm et al. figures (1982). To compare the different estimates of contraceptive use failure rates for adolescents, we need to separate them by medical (Figure 5-5A) and nonmedical (Figure 5–5B) methods because this was the categorization used in the original article (Torres, Forrest, and Eisman, 1980). As one can readily see, there is a great variation in contraceptive use failure rates among the different techniques with the pill and IUD being the most effective. The Forrest et al. (1981) and Schirm et al. (1982) estimates are subdivided further than the Torres et al. (1980) figures and it is necessary to combine them in order to make comparisons among these three sets of numbers. Because the Torres et al. figures are based upon Zelnick and Kantner data (1978a; 1980), one can use their distribution of contraceptive use by the most recent method for women ages 15 to 19 in 1979 as the basis for weighing and combining the Forrest et al. (1981) and Schirm et al. (1982) rates into medical and nonmedical methods of contraception. The results indicate that the Torres et al. (1980) estimates of contraceptive use failure rates are considerably higher for both medical and nonmedical methods than either the Forrest et al. (1981) or Schirm et al. (1982) figures. Even more important, for the purposes of this analysis, the differential between medical and nonmedical methods of contraception are also considerably higher in the Torres et al. study (1980) than either in the Forrest et al. (1981) or Schirm et al. (1982) analyses. The Schirm et al. (1982) figures will result in a larger estimate of the negative impact of any proposed parental notification requirement because the differential between the medical and nonmedical method of contraception

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FIGURE 5-5A. Expected Annual Number of Pregnancies per 100 Sexually Active Adolescents Using Medical Methods of Contraception

is higher than the Forrest et al. figures. However, these figures will be used in this reanalysis of the data because they appear to be more appropriate conceptually and methodologically. It is also necessary to estimate the number of pregnancies that will occur among sexually active teenagers who will not use any form of contraception. In the original article (Torres, Forrest, and Eisman, 1980), the authors assumed that 62.2 percent of those using no method of contraception would become pregnant. The Forrest et al. essay (1981) presents, instead, a range of estimates. A low rate (49.0 percent) is based on a reanalysis of the Zelnik and Kantner data by Zabin et al. (1979), the figures derived from Leridon's (1977) estimates of fecundability, and Zelnik and Kantner's (1977) data on frequency of intercourse for unmarried women ages 15 to 19 who had intercourse during the month before the survey and for onethird of those who did not have intercourse in the previous month. A high rate (64.8 percent) was also calculated from the Leridon (1977) and Zelnik and Kantner (1977) data assuming the rate of

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FIGURE 5-5B. Expected Annual Number of Pregnancies per 100 Sexually Active Adolescents Using Non-Medical Methods of Contraception

intercourse was the same as that for all unmarried teenagers who had intercourse during the previous month. While this is a very difficult issue to resolve, on the whole it seems more reasonable to use the Zabin et al. (1979) figure and the low estimate (Forrest et al., 1981) based upon the Leridon (1977) and Zelnik and Kantner (1977) data. Having arrived at some estimate of contraceptive use failure rates for adolescents, we can now attempt to re-calculate the impact of a parental notification requirement. As indicated earlier in Figure 3, Torres and her colleagues (1980) multiplied the number of teenagers who said they would switch to a nonmedical method of contraception by an estimate of the likelihood of becoming

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FIGURE 5-6. Expected Annual Number of Pregnancies per 100 Sexually Active Adolescents by Method of Contraception

pregnant and added that result to the probable number of pregnancies among those who will continue to be sexually active without using any contraceptives. Because they were interested in ascertaining the net impact of a parental notification requirement, they subtracted from the total the number of pregnancies that would have occurred anyway among adolescents using a prescription method of birth control. They calculated that required parental notification would result in 33,000 additional pregnancies. In redoing their calculations, we can make several important refinements. First, it is necessary to take into account the reduction in pregnancies caused by the 5,500 adolescents who claimed they would stop being sexually active rather than have their parents notified (see Figure 5-4B). Torres and her colleagues only calculated the negative impact of a parental notification requirement and did not consider any of the positive aspects of it. Second, instead of using the rather broad category of nonmedical methods of birth control, it is possible to separate the methods into drugstore contraceptives or withdrawal and rhythm (AGI, 1982). Third, using the distribution of prescription methods obtained by adolescents at family planning clinics (AGI, 1982) as well as the distribution of nonmedical methods currently used by teenagers (Zelnik and Kantner, 1980), one can estimate more precisely the net impact of a shift from one method of contraception to another.11

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Using the contraceptive use failure rates from Schirm et al. (1982) and the figure of 48.6 percent as the likelihood of a sexually active adolescent becoming pregnant if she does not use any contraceptives (Zabin, Kantner, and Zelnik, 1979), a parental notification requirement could result in 11,800 additional pregnancies—or nearly two-thirds less than the original estimate by Torres and her associates (1980). If 64.8 percent were used as the risk of pregnancy among teenagers not using any contraceptives, the estimate would rise to 14,000 additional pregnancies. In order to obtain a better prespective on the influence of alternative assumptions on the final figures, it is useful to make some additional calculations. If we use the original values for the risk of pregnancy (Torres, Forrest, and Eisman, 1980), but incorporate the refinements in the number of adolescents affected by the regulations, the estimated number of additional pregnancies would drop to 15,200. Using the Forrest et al. (1982) figures on contraceptive use failure rates as well as the 64.8 percent estimate of pregnancy among unprotected adolescents, a parental notification requirement might result in 10,800 additional pregnancies (or 13,000 if 48.6 percent is used as the likelihood of pregnancies for adolescents not using any contraceptives). It is interesting to observe that despite large differences among the available adolescent contraceptive use failure rates, the variations in the estimates of the impact of a parental notification requirement are quite small. This is because the analysis of the impact depends upon the differences in the contraceptive use failure rates within any particular set of estimators rather than overall magnitude. If both the contraceptive use failure rates for the pill and the condom, for example, are either high or low, the consequences of shifting from one to another may still be quite similar because the estimate of the effect of shifting from one method to another is based upon the differences between their rates of effectiveness. Some Additional Speculations Up to now this chapter has focused on directly reestimating the probable impact of a parental notification requirement by relying mainly on the data and methodology developed by Torres and

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her associates (1980). Most of the changes introduced have been refinements either in calculating the number of teenagers likely to be affected or improving the estimates of the likelihood of sexually active adolescents becoming pregnant. Although the changes introduced are themselves based upon assumptions and data that may be questioned, the reanalysis up to now has been relatively straightforward. Other considerations exist, more speculative and yet more basic than the earlier ones, which also need to be addressed before one can ascertain the potential impact of a parental notification requirement. For example, the appropriateness of applying contraceptive use failure rates based upon married adults (even young adults) needs to be analyzed—especially from the perspective of coital frequency and adolescent sterility. In general coital frequency is associated with the effectiveness of contraceptive use (Westoff and Ryder, 1977).12 Married couples, especially younger ones, have a higher coital frequency than unmarried adolescents. Trussell and Westoff (1980) found a mean coital frequency of 12.1 for married women under nineteen in 1975 in the four weeks prior to their interview. Zelnik, Kantner, and Ford (1981), on the other hand, discovered that sexually active never-married women ages 15 to 19 in 1976 had a mean coital frequency of 2.6 for a comparable four-week period. Thus, nevermarried teenagers were only about one-fourth as active sexually as their married counterparts. Although we do not know the coital frequency of adolescents attending family planning clinics, coital frequency is higher among those who use a medical rather than a nonmedical method of contraception (3.9 vs. 1.7). It is likely, however, that those teenagers who say they will neither continue coming to a family planning clinic nor go to a private physician are less active sexually than those who are determined to use prescription methods even if it means informing their parents. In any case, even if the mean coital frequency of adolescents who previously had obtained prescription methods from a family planning clinic was 3.9, it still is two-thirds less than that of their married counterparts. Therefore, the contraceptive use failure rates based upon married women (even young ones) may be too high for unmarried adolescents who are less sexually active— although this may be in part offset by the greater expertise and ease

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of using contraceptives by married couples compared to adolescents, who are often only sporadically sexually active. Another major reason why contraceptive use failure rates may be lower for adolescents is because their likelihood of conception is reduced by a period of quasi-sterility after the onset of menarche (Leridon, 1977). This phenomenon is extremely difficult to document and has been ignored in most analyses of adolescents. Even those scholars who are aware of it often think that the occurrence of anovulatory menstrual cycles ends after a year or two and therefore is not important. Recent findings by Apter (1980), for example, suggest that in post-menarchal girls about 80 percent of the cycles were anovulatory in the first year, 50 percent in the third year, and 10 percent in the sixth year (see figure 5-7). The average age at menarche has been declining and is currently about 12.8 years for girls in the United States (Wyshak and Frisch, 1982). The age of menarche is somewhat lower among those who have had sexual intercourse early (Zelnik, Kantner, and Ford, 1981). Therefore, one might guess that the average age of menarche for girls attending a family planning clinic may be as low as 12.0. Using the age distribution of those who say they will not return to the family planning clinic (AGI, 1982) and subtracting them from those who will turn eighteen during the course of the next year as well as those who may go to a private doctor, one can reestimate the number of adolescents by age who will be at an increased risk of pregnancy due to a parental notification requirement. By multiplying each of these age groups by the percentage of expected anovulatory cycles during the next year and adding the results, it is possible to approximate the percentage of likely anovulatory cycles among these adolescents during the next year. Overall, it appears that about one-third of the menstrual cycles for the adolescents who will not return to the clinic or go to a private physician may be anovulatory. Adjusting the estimated impact of a parental notification requirement for the fact that the adolescents are probably two-thirds less sexually active and one-third less fecund than married couples is difficult because one is simply guessing as to what the appropriate level of adjustment should be. A very conservative guess would be to reduce the adolescent contraceptive use failure rates by one-

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Source: Apter, 1980

FIGURE 5-7. Percentage of Anovulatory Cycles According to Gynecological Age (Time in Years since the Menarche)

third or one-half. Using the Schirm et al. (1982) contraceptive failure rates and 48.6 percent (Zabin, Kantner, and Zelnik, 1979) as the likelihood of a sexually active adolescent becoming pregnant if she does not use contraceptives, the impact of a parental notification requirement would be reduced from 11,800 additional pregnancies to 7,900 pregnancies (if contraceptive use failure rates are reduced by one-third) or 5,900 pregnancies (if contraceptive use failure rates are reduced by one-half). Although one cannot be certain exactly what level of adjustment should be made for the lower rate of sexual activity and fecundity among adolescents going to family planning clinics, it is important conceptually and methodologically to make such an adjustment as it can have a substantial effect on the estimated impact of a parental notification requiremhent.

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The Torres et al. analysis (1980) of a parental notification requirement also did not take into consideration the possibility that some teenagers may be exempted from the rule. The Administration's proposed rule (Federal Register, Feb. 22,1982, p. 7700): "permits an exception to the notification requirement where the project director finds it would result in physical harm to the minor by a parent or guardian. The exception is meant to apply to cases where there is evidence of a history of child abuse, sexual abuse, or incest, or where there are other substantial grounds to determine that notification would result in physical harm to the minor by a parent or guardian. The exception does not apply to cases where notification would result in no more than disciplinary actions of an unsubstantial nature."

Exactly how many teenagers would be exempted from notifying their parents is not clear. Using a few replies from family planning providers as well as rough estimates on the extent of previous child abuse and neglect among teenagers, one might guess that about 2 percent of the clinic population or approximately 8,000 to 10,000 cases per year would be exempted from the requirements.13 While this figure does not appear very large at first glance, if one assumes that those adolescent girls who are afraid of being physically abused by the parents due to their prior experiences are among those who do not want their parents notified, the number becomes more significant. For example, of the 106,900 estimated teenagers who would refuse to come to a family planning clinic if their parents had to be notified, approximately 7 to 9 percent of them might be exempted from the proposed regulations on the basis of potential abuse by their parents. While there is no reliable way of calculating the effect of such an exemption clause, any future effort to estimate the impact of the Administration's proposed regulations should at least try to make some tentative adjustments for this possibility. The Torres et al. study (1980) is one-sided in that it concentrates only on the negative aspects of a parental notification requirement and does not consider any potential benefits from increased parental involvement. Some supporters of the proposed federal regulations, for example, point to studies (Fox, 1981; Fox

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and Inazu, 1980; Furstenberg, 1971, 1976; Furstenberg, Markowitz, and Gordis, 1971; Miller, 1976) that show that female adolescents who communicate about sex with their parents, especially their mothers, are more likely to be effective contraceptive users. Other studies, however, (Herceg-Baron and Furstenberg, 1982) question the relationship between mother-daughter communications and effective adolescent contraceptive use. As a result of the limited research on this issue from the perspective of a parental notification regulation as well as the seemingly contradictory results from the various studies cited above, more research is needed to clarify this matter. Even more important, perhaps, is the need to ascertain whether parental knowledge of visits to a family planning clinic might help to overcome adolescents' relatively low return rates. A recent study (Ager, Shea, and Agronow, 1982) of discontinuance in a Planned Parenthood teen contraceptive program found that over an 18-month period, only about 37 percent of clients who ceased their visits either practiced effective contraception or were not at risk of pregnancy during that time. The most frequently cited reasons teenagers gave for stopping the use of contraceptives was the experienced or feared side effects of birth control pills. The clinic was unable to deal with these real or imagined side effects of the pill because teens frequently missed their scheduled followup sessions. The Administration (U.S., Congress, House, Committee on Energy and Commerce, 1982) has suggested that one of the major benefits of increased parental involvement would be that parents could now help their sexually active children use contraceptives more consistently and effectively by reminding them of the need for regular use and by helping them to cope with any unexpected side effects. Also, if the family planning clinics no longer had to be concerned about protecting the privacy of their teenage clients from parents, more systematic and routine follow-up procedures could be instituted. The debate over the positive impact of parental involvement in the use of contraceptives by sexually active adolescents will continue, and any efforts to assess the impact of a parental notification requirement should address this issue. If parental knowledge of visits could reduce adolescent discontinuance of contraceptive use

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by 10 to 15 percent either by better parent-child communications or the development of better clinic follow-up procedures, it might considerably reduce unintended adolescent pregnancies. Finally, we need to consider whether the responses of adolescents going to these larger family planning clinics, according to the Torres et al. survey (1980), are representative of all of the larger facilities and whether the responses vary greatly from one site to another. Although we do not get any sense of the range of answers by site in the published article, Forrest (1982) has indicated that considerable variation existed. For example, among the forty-six clinics with ten or more adolescent requirements, 54.4 percent said their parents already knew of their visit, but that percentage ranged from 20.0 to 89.1 percent (with a standard deviation of 17.7 percent). This variation in response among the different clinic sites helps to account for the fact that several clinic directors, commenting on the proposed parental notification requirements, found the distribution of answers among teens in their own facility very different from the distribution reported by Torres and her colleagues (1980).14 This also raises the question of whether the sample distribution used by Torres et al. (1980) was really representative of all large family planning clinics. Because the distribution of the teen responses is so critical for this exercise, future efforts should devote more attention to the question of clinic sampling errors. Nevertheless, at this time the use of a national sample of large clinics is more defensible than efforts by some individuals to estimate the national impact of the proposed parental notification requirement based on the particular experiences of one or two clinics. Conclusion Despite the widespread acceptance and use of the Torres et al. study (1980) on the impact of the proposed Administration parental notification requirement, it has not been subjected to any detailed scientific scrutiny. This reassessment of its conceptual and methodological assumptions has raised serious questions not only about its appropriateness to the Administration proposal, but also about its overall validity. Even assuming the validity and reliability of the original survey

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of the teenagers (Torres, Forrest, and Eisman, 1980), our recalculation of the likely impact of the proposed parental notification requirement reduces their estimate of 33,000 additional pregnancies to roughly 10,000 to 13,000 additional pregnancies. Furthermore, if the additional speculations about the rate of coital frequency among teens, the length of a period of adolescent quasi-sterility, and the impact of the exemption clause are included, the number of additional pregnancies might be in the range of 5,000 to 8,000, instead of the original estimate of 33,000 pregnancies. This reassessment has not been undertaken in order to replace the estimate of 33,000 additional pregnancies with a more accurate figure, but to demonstrate that the results of the Torres et al. study (1980) should not be accepted and used uncritically. While we should commend Torres and her colleagues for their pioneering study in this difficult area of policy analysis, we must also recognize the serious conceptual and methodological limitations inherent in their analysis. The AGI study (Torres, Forrest, and Eisman, 1980) was used extensively in the debates about parental notification. Both sides cited the essay extensively but used it for different purposes. The opponents of the proposed Title X regulations relied upon the study as the centerpiece of their argument that the new requirements would lead to a great increase in unintended adolescent pregnancies and abortions. The Reagan Administration quoted from the study to demonstrate that some adolescents would stop being sexually active and that most of the remainder would continue to use some form of contraception. Although both sides of the parental notification debate cited the Torres et al. study (1980) and even discussed its scientific merits, neither was totally honest with the American public about its applicability or usefulness as a guide for estimating the impact of the proposed regulations. After the Reagan Administration raised some of the methodological and conceptual issues mentioned in this chapter, AGI acknowledged the limitations of their study for assessing specifically the impact of the proposed regulations: . . . As we have discussed, however, after reviewing available data in the process of preparing for AGI's comments on the proposed regulations, I have concluded that the data currently available to

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AGI would place significant limitations on the usefulness and accuracy of any such estimates. As you know, the data gathered in past AGI studies on the subject of parental involvement do not mesh precisely with the circumstances that would be precipitated by the proposed DHHS regulations. . . . At our meeting, we discussed other concerns about the accuracy of estimating the impact of the proposed regulations. In sum, I think the data now available provide clear indications of the direction of minor patients' responses to regulations such as those proposed, but I feel that exact predictions of the change in the number of pregnancies which might occur will be of dubious accuracy using current data (Forrest, 1982).15

Thus, by July 1982, AGI had acknowledged in a letter to the DHHS the limitations of using the Torres et al. study (1980) to make direct estimates of the impact of the proposed Title X regulations; instead, the study indicated only the possible general directions of adolescent reactions to a parental notification requirement. Although AGI stopped quoting a precise estimate of teenage pregnancies resulting from the proposed requirement, it continued to cite the study as direct proof of the adverse impact of the regulations without fully or clearly informing the public and policymakers about the serious methodological and conceptual limitations of making such inferences. Using the reassessment of the AGI essay (Torres, Forrest, and Eisman, 1980) I provided, the Administration emphasized the inapplicability of that study for analyzing the impact of the proposed regulations (U.S., Federal Register, Jan. 26, 1983: 3606). Yet the Administration, like AGI, was not being entirely candid. It knew that while serious methodological problems did plague the Torres et al. study (1980), the basic conclusion of that investigation remained intact: that a parental notification requirement probably would lead to an increase in unintended pregnancies and abortions—although many fewer than AGI and others had asserted. In addition, although it became apparent that the AGI analysis was not appropriate for directly estimating the impact of the proposed regulations, the Administration still refused to initiate or support any more sophisticated or relevant analyses.16 Thus, while the Administration willingly cited portions of the AGI study that supported its case for parental notification and questioned the overall reliability of that

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analysis, it was not really interested in ascertaining the actual impact of the proposed regulations. The Administration feared that the results might only confirm what the opponents were already saying—that a parental notification requirement might lead to some increase in unintended pregnancies and abortions.

6 Young Fathers and Their Children: Some Historical and Policy Perspectives

In the previous two chapters we have analyzed the formulation and attempted implementation of a policy that would have required parental notification whenever adolescents obtained prescription contraceptives from a federally funded family planning clinic. This major new initiative by the Reagan Administration illustrated a change over the past twenty years in Americans toward the willingness to provide contraceptives to unmarried teenagers. Now we will explore an issue that has received much less attention from policymakers—the role of the young father in adolescent pregnancy. By discussing the situation of the young father within the context of the changing role of fathers in general we will consider how a hitherto neglected aspect of adolescent pregnancy may be gradually emerging as a more important issue. Although the role of the father in child development and care has usually been slighted or even totally ignored, scholars and policymakers seem to have developed a new interest in the issue. Yet many of the recent discussions focus narrowly upon the present without a proper appreciation of the changing role of the American father over time. In addition, many of the current studies concentrate on some particular facet of child development without also considering the broader societal implications of this change—especially from the perspective of policy makers. This chapter will explore some of the issues surrounding the role of fathers in the care and support of young adolescent mothers and 157

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their children by using an historical and policy perspective. We can improve our understanding of the situation of the contemporary father by analyzing the historically changing involvement of fathers in the raising of their children and by examining shifts in the perceptions of the role of males in the problems associated with adolescent pregnancy. To examine the attitude of policymakers toward fathers, we will consider the evolution of the recent federal legislation for helping school-age mothers and their children. The Role of the Father in the Past Today many Americans see the father's role in the care and socialization of young children as secondary or peripheral compared to that of the mother. Indeed, there is a widespread belief that mothers are by nature more suited for the rearing of children. Even the function of the father as the main source of financial support for the young child is often seemingly challenged by the availability of federal, state, or local welfare assistance for single mothers as well as by the reluctance of many adolescent mothers and fathers to marry (Cath, Gurwitt, and Ross, 1982; Lamb, 1981; Lamb and Sagi, 1983). However, in the past the role of the father was more central to the lives of young children (Moran and Vinovskis, 1986). In seventeenth-century New England, for example, strong religious and community pressure kept premarital sexual activity low and encouraged marriage as a solution if an unintended pregnancy occurred. Because the financial burden of raising an out-of-wedlock birth ultimately fell upon a town's inhabitants, the community made every possible effort to ensure that the errant couple married and that the father supported the child. Although mothers worked hard in their homes in colonial America, the father provided the primary and essential source of economic support for his family. The father's responsibilities in seventeenth-century New England extended well beyond the economic support of the children and the mother. The Puritan father, as the undisputed head of the household, had the task of catechizing the children as well as other members of that household (Axtell, 1974). The mother provided

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important assistance, but it was ultimately the father who was responsible for teaching young children to read and interpret the Bible. Although this role stemmed more from general Puritan and English views of the duties of the head of the household, it was reinforced by the fact that New England fathers were more literate than mothers (Auwers, 1980; Lockridge, 1974) and the belief that women could not be entrusted with religious instruction, a result of the difficulties with Anne Hutchinson and her followers in Massachusetts in the 1630s (Hall, 1968). The father's role as disciplinarian was seen as essential in guiding young children; mothers were often viewed as too indulgent and lenient toward their children. Some scholars (Shorter, 1975; Stone, 1977) point to colonial fathers' lack of emotional involvement with their young children, but others (Demos, 1982) argue that many colonial fathers had close, expressive relationships with their children.1 Our ancestors' elevated view of the role of the father in the support and socializing of young children did not differentiate between the responsibilities of adolescent and adult fathers. In contrast with the situation today, Puritan Americans did not distinguish as sharply or clearly between adolescence and adulthood (Demos and Demos, 1969; Miner, 1975; Vinovskis, 1983). Rather, the emphasis was on the transition from a period of economic dependency in youth (whether on one's own family or on some other household) to one of being an adult whose independent status was signaled by the ability to maintain one's own household (Kett, 1977). Only under the latter circumstances was one considered eligible for marriage. As a result, relatively few young adolescent females or males married in New England and such marriages did not arouse concern unless the family lacked financial support (Greven, 1970; Jones, 1981; Norton, 1981; Vinovskis, 1981b).2 Thus, in seventeenth-century New England, fathers were the primary and necessary providers for their children. Mothers nursed and cared for the physical needs of the young child, but the father catechized and socialized the young children. Early adolescent childbearing and rearing did occur, but as we saw in chapter one, it was not widespread or considered problematic. During the eighteenth century, we can observe some fundamental changes in the role of fathers. The strong and aggressive prohibi-

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tion against premarital sexual relations eased during the eighteenth century. Premarital sexual relations became an expected if not accepted part of colonial courtship rituals. As a result, the number and rate of premarital pregnancies increased during the second half of the eighteenth century (Smith and Hindus, 1975). While most of these resulted in a hastily arranged marriage, society also became more tolerant of out-of-wedlock births. Yet the community still feared being saddled with the care of indigent unwed mothers and their children. Fathers were forced to support their offspring whenever possible even if they managed to avoid marrying the mother (Wells, 1980). Perhaps the most important change in the role of the colonial father was the relinquishment of his catechizing functions in the household. By the mid-seventeenth century, males were much less likely to join the Puritan church than females (Moran, 1980). Because the duties of catechizing rested on a religious foundation, many fathers were no longer able or willing to provide religious instruction. Instead, community and church leaders experimented with a wide variety of other options for catechizing such as enlisting public school teachers. They reluctantly accepted the larger role of the mother in this task, as women continued to be active members of the church (Moran and Vinovskis, 1982,1986). One consequence of this shift was the growing sentiment that women should be educated in order to better provide religious education for their children (Malmsheimer, 1973; Ulrich, 1982). The American Revolution also contributed to the expansion of women's roles, reinforcing the mother's part in educating children (Kerber, 1980; Norton, 1980). As a result, by the eighteenth century, the mother's contribution to the physical and spiritual care of young children had expanded considerably while the responsibilities of the father had gradually contracted in practice as well as in theory.3 Thus, in eighteenth-century America, fathers were expected to support their offspring even if they did not marry the mother. While the attitudes toward adolescent parents remained neutral, a dramatic shift occurred in the relative roles of the mother and father. Whereas the seventeenth-century father acted as the primary religious instructor of his children in the home, the eighteenth-century family frequently delegated this task to the mother. Some lamented the diminished role of the father in the socializa-

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tion of the child, but most accepted it and concentrated on preparing the mother for her new responsibilities. The nineteenth century witnessed an extreme shift in attitudes toward premarital sexual activity and a further expansion of mother's role in the care and socialization of young children at the expense of the father's role. This period also saw the emergence of adolescence as a concept and growth in the role of the state rather than the local community in the care of poor mothers and their children. Thus, the nineteenth century served as an important bridge between the colonial period and the twentieth century in the changing attitudes and behavior toward the role and rights of fathers in the care of their children. Increasingly in the early nineteenth century, Americans regarded premarital sexual activity as sinful and shameful. Due to the religious zeal of the Second Great Awakening as well as a more general redefinition of appropriate courtship behavior, women who became pregnant prior to marriage were treated as outcasts—especially if they did not marry the father. As a result, premarital pregnancies dropped dramatically in the nineteenth century, accompanied by an apparent rise in abortions as single women increasingly tried to eliminate a potential source of great shame and rebuke (Mohr, 1978; Smith and Hindus, 1975). Society increasingly defined respectability as being chaste prior to marriage or, at the very minimum, marrying the father if one became pregnant (Rothman, 1984). Although most nineteenth-century Americans accepted these new values, some strongly resented the double-standard that punished the behavior of the women but allowed men to behave with impunity (Smith-Rosenberg, 1971). Once a nineteenth-century woman became a mother, the extent and complexity of her tasks multiplied and expanded. Although the authors of popular advice literature often expressed the wish that fathers would take a more active role in the upbringing of their children, most reluctantly accepted the fact that fathers were too busy with their careers and jobs to play a large role in the socialization of their children (Kuhn, 1947). The increasing likelihood that the father would now work outside the home reduced the opportunities and amount of time that he would have to interact with his family—especially as the availability of transportation separated the home from the workplace by even greater distances (Warner,

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1963). While the evangelical press frequently exhorted fathers to pray for their families and children, women continued to be the more active and involved parent in the catechizing of children in the home (Ryan, 1981). Women also expanded their role in the religious realm by outnumbering men as teachers in newly created Sunday schools (Sweet, 1983). The scientific and educational community stressed the mother's role in child development and education, emphasizing her particular suitability for the care of young children (May and Vinovskis, 1977). The nineteenth-century doctrine of "separate spheres" and the "cult of domesticity" asserted that women were especially suited to raising and educating young children while men were better able to make a living outside the home (Cott, 1977; Degler, 1980). Almost all of the authors of nineteenth-century childrearing manuals and advice books directed their words to mothers with only passing references to the role of fathers (Demos, 1982). The mid-nineteenth century also saw a growing disposition among judges in divorce cases to award the custody of children, especially young ones, to the mother rather than to the father (Griswold, 1982; Grossberg, 1983; May, 1980; Zinaldin, 1979). Previously the courts had assumed that in almost any divorce or separation case, the custody of the children should be given to the father rather than to the mother so that the pattern of male inheritance and dominance could be continued. However, in the second half of the nineteenth-century, as the number of divorces in the United States began to increase rapidly, justices increasingly took into consideration the interests and well-being of the child. Given the nineteenthcentury view of the mother's important role in the care and rearing of young children, it is not surprising that the fathers received custody of the children less often. In the twentieth century, of course, the evolution has continued to the point where the mother rather than the father almost automatically receives the custody of young children unless she seems to be unfit or unwilling to raise them (Weitzman and Dixon, 1979). During the second half of the nineteenth century adolescence emerged as a separate and distinct stage of life, and society began to treat young adolescents differently than adults. Although historians continue to disagree upon the exact timing of society's recognition of adolescence as a phase in the life course, most now locate

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that development somewhere in the nineteenth century (Demos and Demos, 1969; Vinovskis, 1983). Parents encouraged teenagers to postpone marriage, even if they were economically self-sufficient, and pressured sons especially to acquire additional education or some other type of job training. In addition, medical authorities saw any early sexual activity as extremely detrimental to the physical and mental development of the adolescent (Clarke, 1873). This distinction between adolescents and adults received practical reinforcement with the creation of special institutions such as juvenile courts and homes for unwed adolescent mothers (Brenzel, 1975; Brumberg, 1985; Schlossman and Wallach, 1980). Finally, the nineteenth century witnessed the increasing involvement of the state and national government in the care of the poor, sometimes supplementing the local community's role (Rothman, 1971). This assistance was often provided through state institutions, which became more common and specialized over time. Because of the growing tendency by social reformers to make distinctions between the "deserving" poor and those unworthy of support, special efforts were made to provide for helpless single mothers and their young children. While these developments remained relatively modest at the end of the nineteenth century, they created the twentieth-century precedents and expectations for the expansion of the role of the state and then the federal government in these areas.4 By the 1950s scholars and laymen alike accepted the diminished role of the father in the rearing of the young child. Fathers were viewed as necessary for the economic well-being of the family, but it was the mother who provided primary care for the young. Compared to the nineteenth century, the first half of the twentieth century saw a shift away from the strict prohibition against any premarital sexual activity. Yet if a girl became pregnant, especially among the white population, the couple usually married (Cutright, 1972). Parents and educators cautioned children against becoming sexually involved or marrying too early, but their advice was frequently ignored. In 1957 adolescent childbearing reached its peak of 97.3 births per 1,000 women ages 15 to 19 (Vinovskis, 1981a). Even though the incidence of early childbearing was rising, most public schools did not tolerate adolescent pregnancies. Pregnant teenagers, even married girls, were usually forced to drop out of

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school and young mothers were discouraged from reentering their regular high school classes (Stine, 1964). Pregnant girls who did not marry often sought illegal abortions despite the considerable physical and legal risks involved (Polgar and Fried, 1976). Unmarried adolescents who decided to have their babies went quietly to a maternity home in another community and were encouraged to place the child up for adoption (Sedlack, 1980). Thus, although teenage childbearing in the 1950s became very common, public attitudes toward the young mother and her child continued to be negative, especially if she remained single. Although these young mothers could receive some federal, state, and local welfare support, the stigma attached to the receipt of this assistance was considerable and the funds furnished minimal. During the 1960s and early 1970s, some important changes led to the reconsideration of the treatment accorded to pregnant adolescents. Premarital sexual activity became more common and acceptable. By 1971, approximately one out of four unmarried teenage girls ages 15 to 19 had experienced intercourse (and nearly half of those ages eighteen or nineteen) (Zelnik and Kantner, 1977). Although the rate of teenage childbearing fell, the total number of children born to adolescents increased as did the likelihood of having an abortion—especially after the Supreme Court liberalization of abortion laws in 1973 (Moore and Burt, 1982). The alarming rise in out-of-wedlock births among teenagers particularly disturbed many Americans. Whereas fathers in the 1950s had typically married the pregnant adolescent, about one-third of the children born to teenagers in the early 1970s were out-ofwedlock (Moore and Burt, 1982). Americans were not particularly concerned about the lack of paternal care for these children, but they were upset by the increased welfare costs as the amount and types of public assistance available increased during these years (Moore, 1978). While many people worried about the so-called "epidemic' of adolescent pregnancy and looked to ways to curtailing it, a few individuals also looked for ways to help young mothers and their children (Vinovskis, 1981 a). Reflecting the growing stress placed upon high school graduation in the 1960s and the expectation that many of these young mothers would eventually need to enter the labor force, demonstration sites such as the Webster School in

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Washington, D.C. in the 1960s and early 1970s made efforts to help adolescent mothers continue their education. In addition, these programs emphasized the need for comprehensive medical and social services for the adolescent's child in order to ensure its healthy development and to minimize any of the problems associated with births to teenagers (Klerman, 1981). Although these concerned citizens did mention the role of the father from time to time, the mother and the child received their primary, if not exclusive, attention. Policymakers and the Role of the Father So far we have considered the changing role of the father in the care and support of young children from the seventeenth to the twentieth centuries. Although colonial Americans placed the father in a position of centrality in the socialization of the children, by the 1970s the father was seen as a peripheral source of paternal interaction with the child and had even lost his role as the main source of economic support. In order to find out whether policymakers also saw the father as less important, we will review the efforts to create a federal program of comprehensive care for adolescent mothers and their children in 1975, 1978, and 1981 and see what role, if any, was envisioned for the young father. School-Age Mother and Child Health Act, 1975 During the late 1960s and early 1970s a small group of individuals sought to alleviate the plight of school-age mothers by persuading the government to develop and fund comprehensive care services for adolescent mothers and their children. It soon became obvious to these advocates that without substantial federal involvement and aid, only a small handful of these adolescents would be helped. Therefore, the National Alliance Concerned with School-Age Parents (NACSAP) and Eunice Shriver of the Joseph P. Kennedy Jr., Foundation persuaded Senator Edward Kennedy (D-MA), chairman of the Subcommittee on Health of the Senate Committee on

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Labor and Public Welfare, to introduce a "National School-Age Mother and Child Health Act" (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975). Although this legislation had little chance of passing in the closing days of that session, its supporters felt that the extensive hearings on the bill on November 4, 1975, would be an opportunity to publicize the needs of schoolage mothers and their children and to lay the foundation for future legislation in this area.5 Despite the nearly nine hundred pages of testimony at the hearings and in the bill itself, only a few scattered references can be found to the role of the father in the support and care of young children (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975). The legislation mentions the need to help adolescent parents, yet the bill focuses almost exclusively on the needs of the adolescent mother and her child. Among the eleven comprehensive services to be provided under this legislation fathers are mentioned only in regards to counseling for both parents. Only the school-age mother is eligible for other services, such as educational and vocational training. We should not be surprised by the neglect of the father's role in the proposed Kennedy bill as its proponents usually assumed that the recipient of this assistance would be an unmarried pregnant adolescent. The draft bill did state that adolescents would be eligible for these services regardless of their marital status. However, most witnesses assumed that this meant that the bill targeted unmarried female adolescents and thus there was little opportunity to involve the father. The exclusive focus on female adolescents was common to critics as well as supporters of the bill. Dale Sopper, Acting Deputy Assistant Secretary for Legislation (Health), Department of Health, Education , and Welfare (DHEW), testified against the proposed legislation on behalf of the Ford Administration calling it unnecessary and a duplication of existing federal programs (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 23). Both his testimony and that of other Administration officials emphasized services for adolescent mothers and their children with almost no apparent awareness of the existence or importance of the father. Despite the growing problem of out-of-wedlock adolescent births, most of the supporters of this legislation did not argue that

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fathers should be encouraged to marry the pregnant adolescents or that efforts should be made to support teenage marriages. Instead, most witnesses as well as several senators denounced punitive attitudes and behavior toward unmarried pregnant adolescents and looked for ways to overcome this handicap. They claimed that the stigma attached to adolescent out-of-wedlock pregnancies and births led to an increased number of abortions and a high rate of school dropout among these girls. Thus, rather than encouraging fathers to be actively involved with their children, the commentators neglected them altogether. Some witnesses even questioned the advisability of involving fathers at all. James Jeckel, Associate Professor of Public Health at Yale University, testified that: Many people talk about the importance of including the fathers in the programs. Whereas I do not think they should be categorically excluded from programs (and the bill does not), we have some data (as yet unpublished) that shows relatively few of these young mothers eventually marry the putative fathers, and that those adolescents who marry early tend to have more children than those who do not, and their marriages are unstable. It is my judgment that we are not yet ready to encourage the inclusion of fathers in most phases of specific programs for the mothers (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 380)

The only real dissent from the position of virtually ignoring the involvement of fathers came in written testimony submitted to the Senate by the Illinois Association for Comprehensive Services to School Age Parents Inc. Most of the twelve pages of testimony submitted simply documented the existence and nature of adolescent pregnancy and childbearing in Illinois communities, but in the section of recommendations, it urged amending the legislation in order to provide all of the relevant comprehensive care services for fathers as well as mothers. The Association writes: We urge that the scope of the Bill be expanded to include the school-age father. He is often forgotten as a person with needs, and is often sought out for punitive action. Observations of professionals and research has pointed out that he can be a source of support

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to the mother and child and often truly interested in the fate of the offspring. Curtailment of services will more likely discourage him from active involvement and interest in the welfare of the mother and child. (U.S. Congress, Senate, Committee on Labor and Public Welfare, 1975: 595)

This effort to recognize the special needs and contributions of the school-age father was ignored and forgotten. The "School-Age Mother and Child Health Act of 1975" was not enacted, but it did provide the intellectual and political context for subsequent debates in 1978.

Adolescent Health, Services, and Pregnancy Prevention Act of 1978 The creation of federal programs to care for pregnant adolescents and young mothers received much more attention in 1978 when the Carter Administration made the issue of teenage pregnancy and childbearing one of its highest domestic priorities for FY1979. The Administration proposed allocating an additional $148 million to deal with these problems—including the new $60 million "Adolescent Health, Services, and Pregnancy Prevention Act of 1978." This legislation had grown out of the earlier unsuccessful "SchoolAge Mother and Child Health Act" and from the recommendations of the Administration' so-called "Alternatives to Abortion" inter-agency task force (Vinovskis, 1981a). As we have seen in Chapters Two and Three, four different committees debated the Administration proposal in the U.S. Congress, a much more extensive discussion than had taken place three years earlier. During the testimony on this legislation, it became apparent that the bill would serve adolescent girls and their children almost exclusively. Although the debates indicated that a comprehensive service such as counseling might be available for both parents, the testimony of Joseph Califano, Secretary of DHEW, as well as those of other members of the Administration reiterated that the adolescent girl and her child remained the primary concern. Indeed, most witnesses almost entirely ignored the existence or involvement of the father (U.S. Congress, Senate, Committee on Human Resources, 1978).

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Some witnesses did stress the need for male involvement in the prevention of unintended adolescent pregnancies. The U.S. House Select Committee on Population, which emphasized prevention, even chastized the Administration for not involving more males in family planning clinics. Yet while the Select Committee Report discussed comprehensive care services for pregnant teens or young mothers and their children, it failed to acknowledge or mention the role of the father (U.S. Congress, House, Select Committee on Population, 1978b).6 Although only a few individuals discussed the need for involving fathers in the support or care of the adolescent mother and child, several of the existing service program descriptions submitted did mention that fathers could receive counseling services at their facility. Furthermore, one young man provided a dramatic illustration of the problems of the adolescent father to the Senate Subcommittee on Health as he described his reactions and experiences after discovering that his girlfriend was pregnant: Well, I imagine my original reaction was one of fear—I was scared, along with Joanne. We both had tremendous fears of what the future would bring for us. We knew that our lives would be changed dramatically within the next couple months, the rest of our lives. I was greatly worried about our making it as a family; would we be able to possibly make a go of it. At the time, I was working on a part-time basis and I knew there was no way I could finance a family of three. So, luckily, we got a lot of support from our parents and were able to move in with them until I could graduate from school. At that time, I got a job as an apprentice and from there, I completed the apprenticeship program. Also emotionally, it is very difficult to adjust. As Joanne was saying, you are completely isolated. I had no activities of my own. I went to school and immediately after classes I went to work. I worked until late at night, and then I would come home and it was time for homework. Consequently, you just have no other time for anything else. It is very difficult (U.S. Congress, Senate, Committee on Human Resources, 1978:128)

This moving testimony demonstrated the problems faced by young fathers and evoked considerable sympathy from the few senators present at the hearing. But the larger issue of the role the

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father plays in the development of the young child was not pursued. Indeed, although several experts later testified about the developmental problems facing children of adolescent parents, they did not acknowledge the father's role in raising a young child. Most references to fathers in the hearings in 1975 and 1978 were favorable and frequently alluded to the stress they experienced as a result of the unintended pregnancy. But some witnesses, especially those before the House Select Committee on Population, even questioned the importance of the involvement of the father, implicitly if not explicitly—especially if it meant a "shot-gun" marriage. Wendy Baldwin, from the Center for Population Reearch of NICHD, argued that society should not necessarily encourage pregnant teenagers to marry: Adolescents who marry may not be better off and, in some ways, worse off than their peers who don't marry. The rates of marital disruption among young teenagers are high and there appears to be a greater likelihood of an earlier second pregnancy among those who marry. It is not clear that marriage is really a solution especially for the very young teenager. (U.S. Congress, House, Select Committee on Population, 1978a: 10) Rather than marrying the father, many of the social scientists recommended that the pregnant adolescent girl stay with her parents and continue going to school. As Harriet Presser, a sociologist from the University of Maryland, observed: I might add, in reference to the earlier discussion, that one of the reasons that girls do not marry the father of their child, based on their study, is that the girl's parents can often be more supportive than the father in enabling them to return to school. If the young woman is living with her family, her mother might help take care of her child while she returns to school. If, instead, she leaves the household and gets married, the father of the child is not likely to do this. She may, therefore, trade off marriage for going back to school. (U.S. Congress, House, Select Committee on Population, 1978a: 27) The question of whether or not pregnant teenagers should be encouraged to marry did not receive adequate discussion and con-

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sideration at these hearings. Even if the pregnant unmarried teenager is more apt to remain in school, what are the costs of this strategy to the her parents or the public? What are the disadvantages to the child of being raised out-of-wedlock? On the other hand, if she does marry, how does this affect her own educational development and that of her husband? If the couple divorces, are any of the advantages of paternal involvement for the development of the young child lost? If several of the social scientists testifying in the House were convinced that pregnant adolescents, especially young ones, should not necessarily be encouraged to marry, Senator S. I. Hayakawa (R-CA) disagreed in the other chamber. He angerly denounced young fathers for their lack of involvement and responsibility: Now, the one thing that I miss in all of this legislation, all the concern, I miss concern with the fathers of these children. They do not seem to have any responsibility in any of this, and what is to prevent, therefore, these young men or these boys from going on to produce, one after the other, out-of-wedlock babies, while cheerfully continuing with their studies, finishing high school, finishing college, leaving behind a whole trail of unmarried mothers and fatherless children to be taken care of by HEW and local agencies. Is there within this program, or within all the people who are thinking about it, any concern with making the young men involved face some of the responsibilities that they are placing upon society? I see none. I see evidence, on the other hand, of a male-dominated society that wants to let the boys off free, wherever possible, while we cluck, cluck, cluck, over the girls. And, Mr. Chairman, I want to protest this absence of concern with the male parties to this social problem. (U.S. Congress, Senate, Committee on Human Resources, 1978:90).

Senator Edward Kennedy angerly responded not by denying Hayakawa's assertions, but by reminding him that a similar protest against the lack of male responsibility could be made in regard to federal support of family planning programs or abortions. As Kennedy put it, "I would have been interested in my good friend and colleague from California raising those same issues on that issue (family planning), rather than targeting out this issue here, trying

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to deal with a particular problem" (U.S. Congress, Senate, Committee on Human Resources, 1978: 91). Senator Kennedy then went on to say that "as I understand a very significant part of the parenting aspects of this bill that are included in there, it would also try to bring that special responsibility to young men, as well" (U.S. Congress, Senate, Committee on Human Resources, 1978: 91). Although Secretary Califano had up to then almost totally ignored the role of fathers in either the legislation or his own testimony, he quickly concurred with Senator Kennedy's observation. Perhaps this sharp exchange between Senators Hayakawa and Kennedy helps to explain why DHEW, which had previously paid scant attention to the role of fathers, suddenly seemed to reverse itself in subsequent answers to written questions from the House Subcommittee on Health and the Environment. Replying to the question of "why have the needs and responsibilities of the young adolescent male been generally ignored by the Administration's program," the department responded at considerable length: Although a few programs have begun to include some type of male strategy, there is not wide agreement on how teenage males should be approached. Current efforts in family planning programs have not been particularly successful, although there is male involvement in some comprehensive programs . . . Comprehensive Adolescent Pregnancy Programs involve males in the following kinds of activities: 1. Counselling sessions about pregnancy prevention and sexual responsibility. These sessions are held with males alone, and also with males and females together. 2. Group "rap" sessions with both fathers and non-fathers regarding pregnancy prevention. 3. Social workers assist the males in continuing with their education, enrolling in vocational education and manpower training programs, finding and holding jobs, budgeting their personal funds, etc. 4. Prospective fathers participate in the following kinds of activities: a) The mother's preparation for childbirth b) His presence in the delivery room itself c) Parenting instruction

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Relationship between adolescent mother and father Family problems that may result from pregnancy Legal concerns of the male Financial responsibilities to the child.

Under our new legislation, we will be asking each program to describe how they propose to deal with adolescent males. The legislation has been drafted with a broad mandate for innovative program development to allow communities to experiment and develop approaches to adolescent males which best work in their communities. From these experiences as well as what we learn from the limited number of programs already involved in this area, we will work to stimulate interest in expansion of this area and to share with communities the results of various program approaches. (U.S. Congress, House, Committee on Interstate and Foreign Commerce, 1978: 37)

Thus, the Carter Administration, which had not paid much attention to the role of the father in dealing with adolescent pregnancy, now endorsed a more comprehensive and ambitious approach for helping adolescent males. But, the policymakers did not, and could not, escape from the original dilemma posed by different perspectives on the father at the hearings. While almost all of the individuals who mentioned the young father sought to help him in coping with his own difficulties or to minimize the extent of his involvement by discouraging marriage, a few others such as Senator Hayakawa wanted fathers to assume a larger moral and financial responsibility for their out-of-wedlock offspring and advocated punitive measures to increase paternal involvement. Almost no one at the Senate and House hearings argued that increased paternal involvement should be encouraged because it might enhance the early development of the new-born child. The Adolescent Family Life Program of 1981 In Chapter Three we examined the origins of the Office of Adolescent Pregnancy Programs (OAPP) in 1978 under Lulu Mae Nix. Despite the seemingly strong endorsement of OAPP and its mandate from the Carter Administration and the 95th Congress, the

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program actually received very little money. Instead of the $50 million authorized for FY1979, $1 million was appropriated in July 1979 in a supplemental budget and only $7.5 million for FY1980 and $10 million for FY1981. In FY1979 OAPP funded only four comprehensive care projects and then added another twenty-three new grants in FY1980. Partly as the result of the reduced funding and partly as a reflection of the orientation of the director toward care programs for pregnant teens or young parents, OAPP ignored the prevention aspects of the original legislation during Nix's tenure in office. As male involvement is usually emphasized more in pregnancy prevention than in pregnancy care programs, the neglect of this area undoubtedly minimized the number of young teenage boys reached by the OAPP funded programs. In describing the goals of OAPP to the public and potential grantees, the initial emphasis was clearly on the needs of the female adolescent and the child. Yet the young father was not categorically excluded. Indeed, when Dr. Nix requested that grant applications provide a step-by-step explanation of how services would be delivered, she stated that "I would like to pick up an application and see clearly how each adolescent, infant, father, and family will be processed through that program." In addition, when she called for community involvement, she urged the applicants to "Remember, this is a man's issue, too, and it crosses all economic lines. Include men as well as women on your boards and committees" (Office of Adolescent Pregnancy Programs, 1980). While the original OAPP plans for programs did not exclude males and young fathers, neither did they emphasize their participation. Usually male participation meant only the provision of counseling for teenage fathers as part of the general services available to any member of the extended family. A few programs under this Title VI legislation did try to make some special efforts to involve males, but most of these operations assisted males only if the fathers came on their own initiative. As a result, the Urban Institute evaluation of OAPP programs found that only about 10 percent of the clients were males because "the primary focus has been on mothers and mothers-to-be" (Burt, Kimmich, Goldmuntz, and Sonenstein, 1984: 25). Because so few males were served and because the pro-

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grams viewed their involvement as peripheral, the Urban Institute evaluation decided not even to analyze the effects of male participation under the Title VI legislation. The election of Ronald Reagan resulted in major changes in OAPP. In March 1981, Marjory Mecklenburg replaced Lulu Mae Nix as the Director of OAPP and the new Administration proposed and succeeded in having the Title VI program placed into a block grant. At the same time, Senators Jeremiah Denton (R-AL) and Orrin G. Hatch (R-UT) introduced the Adolescent Family Life bill as Title XX of the Public Health Service Act of 1981 (U.S. Congress, Senate, Committee on Labor and Human Resources, 1981b). Although many of the goals and the intended scope of the Adolescent Family Life bill differed from those of its predecessor, there was also considerable continuity—in large part as a result of the need to obtain co-operation and active support from Senator Edward Kennedy (D-MA), who insisted on leaving the comprehensive care portions of the earlier legislation intact. As we discussed in Chapter Three, the authors of the Title XX Adolescent Family Life legislation designed it as a small federal program to develop model demonstration projects and to encourage basic research. At least two-thirds of the funds were to go to service providers who would develop model care programs for pregnant adolescents and young mothers or for prevention projects designed to discourage early sexual activity among teens. Up to one-third of the funds could be used for primary research on problems associated with adolescent sexuality, pregnancy, and early childbearing. Unlike the 1978 situation, supporters and opponents of the legislation had very little opportunity to discuss its merits. The House did not hold hearings on the proposed legislation and the sessions in the Senate focused largely on issues involving the provision of family planning services to teenagers (U.S. Congress, Senate, Committee on Labor and Human Resources, 1981a). The role of adolescent males received very little mention or discussion during the Adolescent Family Life hearings. Similarly, while the Title XX legislation allows for the inclusion of males in the prevention or care projects, it did not emphasize their participation or detail the manner in which it should be enhanced. Issues such as family

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involvement and adoption, for example, received much more attention in the new legislation than did young fathers. Although the legislative process in 1981 did not pay much attention to the role of males or young fathers, some of the later programs funded by OAPP, especially those emphasizing prevention, did try to involve them (U.S. Congress, House, Committee on Energy and Commerce, 1984). Terrence D. Olsen, for example, is developing an Alternative National Curriculum, which emphasizes the prevention of early sexual activity, and is now testing it on male and female students at selected public schools in Utah, California, and New Mexico. The Youth Health Services of Elkins, W.Va. also provides services such as vocational education to young fathers. Arthur Elster of the University of Utah College of Medicine is working with adolescent fathers in a comprehensive teenage pregnancy program that is particularly innovative and interesting. Thus, while most OAPP grantees still focus mainly on the needs of the adolescent girls and their children, a few are trying to develop and evaluate the provision of special services for young males and teenage fathers.7 The interest of OAPP in fathers is also reflected in its research agenda. On May 10, 1984, OAPP requested proposals on "The Characteristics and Family Involvement of Fathers of Adolescent Premaritally Conceived Births." The six items listed in that request deal extensively with the father's role: "1. What are the demographic, social, ethnic, and economic characteristics of the fathers of babies born to single teenage women? To what extent are they different than fathers of babies born to married teenagers? 2. In what ways and to what extent are the fathers of out-ofwedlock teenage births involved in the lives of the mothers and children, socially and financially? Is their involvement different from that of fathers of babies born to married teenagers? 3. What are the social, economic, health, and developmental consequences of fathers' involvement in the lives of their out-ofwedlock children? Are those consequences different from the consequences of involvement with fathers of babies born to married teenagers? 4. Are the problems of teenage fathers of children born to single

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adolescent mothers very different from those of older fathers of adolescent mothers? 5. What can be done to alleviate some of the difficulties facing fathers of children born to adolescent women while at the same time increasing their involvement with and responsibility for the young mother and child? 6. What are the advantages and disadvantages of fathers not marrying the pregnant adolescent from the point of view of the young mother, the child, the father, and society as a whole?" (U.S. Federal Register, 1984:19897) The Reagan Administration has taken an extensive and broad interest in fathers. Recently, OAPP has focused not only on the father's needs and his interactions with his child, but also on his financial responsibility to his new family. As OAPP's request for research states: "Whether or not fathers are socially involved, they may be economically involved with the unwed mother and her child. It is often assumed that the fathers of out-of-wedlock adolescent births are adolescents themselves, and therefore are unable to contribute financially to the support of the unwed mother and child. But the fathers tend to be several years older than the mothers, old enough for many of them to have completed high school and found jobs. Many are capable, therefore, of contributing financially at the time of the pregnancy and birth, many become able to do so at some time during the infancy of the child. Furthermore, if the father cannot contribute, his family (the paternal grandparents of the out-ofwedlock baby) may be able to do so. Of course, financial support from any paternal source at any time may have an important impact on the economic circumstances of the unwed mother and her family; also, it might reduce the burden of public welfare." (U.S. Federal Register, 1984: 19896) Whereas many practitioners in the field of adolescent pregnancy concentrate only on the problems or needs of the teenage father, the recent OAPP initiative expresses equal concern about older males involved with adolescent girls—especially because the latter may be in a much better position to contribute to the support of the young mother and child. The Reagan Administration also does not accept the notion, advanced by several scholars at the hearings on adoles-

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cent pregnancy, that teenage marriages are necessarily disadvantageous to the pregnant adolescent. Indeed, one of the first research contracts funded by OAPP under the new Title XX legislation was to the Human Affairs Research Centers of the Battelle Memorial Institute to analyze the effect that marriage has on the pregnant adolescents, their children, their partners and their families.8 Thus, while the role of fathers in adolescent pregnancy was not a primary consideration for most congressmen and witnesses in 1975, 1978, or 1981 or among researchers and practitioners in this field, the Office of Adolescent Pregnancy Programs under Marjory Mecklenburg has highlighted the issue. Although the Administration does acknowledge the importance of the father in the development of the child as well as dealing with his own problems and needs, recent federal efforts concentrate on increasing the father's economic contributions to the mother and child. It is still too early to judge the impact of this new orientation, especially as the results from these demonstration programs and research initiatives are currently unavailable, but it is likely that in the future much more attention will be paid to the role of the father in teenage pregnancies.9 Conclusion In the past, the father's role was central to the well-being of the family and the socialization of its members. During the colonial period, society expected the father not only to provide for the child's economic needs, but also for its spiritual education. Puritans regarded the mother as an essential assistant to the father in caring for the child, but placed the primary responsibility for support and edcucation upon the father. Early Americans made no distinction between adolescent and adult fathers in the assignment of these tasks. If a father failed to live up to his obligations to his family, the state willingly intervened to ensure that the welfare of society as a whole would not be endangered. Because of a series of historical developments that have tended to minimize the father's role in the care and support of his children, the mother is now seen as "naturally" suited for raising the children. However, scholars have recently rediscovered and con-

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firmed the father's important role in childrearing. Unsurprisingly, when policymakers confronted the issue of adolescent childbearing in the 1970s, they gave little thought or attention to the responsibilities or needs of the father. Indeed, in the attempts to help the young mother and her child, little effort was made to involve the father and many even suggested that it would be counterproductive to encourage adolescent marriage. The legislators who initially developed federal programs for assisting pregnant adolescents or young mothers and their children were not particularly concerned about forcing the putative fathers to support their offspring, but others in the Congress soon called for more effective and coercive child-support programs (Chambers, 1979). During the Carter Administration, little overlap existed between the efforts to help pregnant teens and the efforts to make fathers support their children but preliminary actions indicate that the Reagan Administration intends to change this by urging the Office of Adolescent Programs to explore ways of involving fathers in the care and support of their children. Whether that involvement will consist mainly of forcing these fathers to contribute financially or of encouraging them to help in the rearing of their offspring is unclear. Nor is it clear how the Reagan Administration would alter the Adolescent Family Life programs in order to acccommodate both increased father involvement in childrearing and the defrayal of societal costs associated with adolescent pregnancy. In any case, the role of the father in the care and support of the children of adolescent mothers is likely to reemerge in the 1980's and contribute to the more general reexamination of the rights and responsibilities of fathers in our society today (Chase-Lansdale and Vinovskis, 1987).

7 Evaluations of Care Programs for Pregnant Adolescents and Young Mothers

The use of evaluations to assist policymaking and guide program development has increased dramatically during the past twenty years. In the 1960s evaluation become a normal and expected component of many federal programs. As Robert Finch, then Secretary of Health, Education and Welfare (DHEW) testified before the House Committee on Education and Labor in 1969: Evaluation is necessary for effective implementation and judicious modification of ... existing programs .. . .Evaluation is probably more important than the addition of new laws to an already extensive list of ... statutes. . . . Evaluation will provide . . . information to strengthen weak programs and drop those which simply are not fulfilling the objectives intended by the Congress when the programs were enacted (quoted in Abert, 1979, vol. 1:1).

Evaluations have played a key role in the formulation and implementation of programs for pregnant adolescents and young mothers starting with the demonstration efforts of the Children's Bureau in the early 1960s and continuing with the activities of the Office of Adolescent Pregnancy Programs (OAPP) in the mid1980s. Indeed, as seen in earlier chapters, program evaluation became a major issue in the 1975, 1978, and 1981 debates over the enactment of federal legislation to provide adolescent services. 180

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No one has adequately surveyed the types and quality of evaluations produced by evaluators working with care programs for pregnant adolescents, or analyzed their impact on policymaking and program implementation during the past two decades.1 An assessment of these program evaluations is timely and useful because it could provide guidance for future initiatives in the area of adolescent pregnancy. Such assessment also provides some general insights into the ways in which applied social science research is produced by scholars and interpreted by the federal government. The Children's Bureau and Early Evaluations of Care Programs When the Children's Bureau of DHEW initiated a program in the early 1960s to provide services for school-age mothers, it required the projects receiving funds to include an ongoing evaluation. Much of this insistence upon program evaluation and the success of these undertakings resulted from the initiatives of the Director of the Research Division of the Children's Bureau, Charles P. Gershenson (Furstenberg, 1976). His pioneering vision of the importance of evaluation not only generated useful studies and stimulated several social scientists to become involved in program evaluation, but also established a precedent and tradition for evaluating care projects that has had a lasting impact on developments in this field. As a result, program evaluation has played a larger role in the provision of care services for pregnant teenagers than in the delivery of family planning services.2 One of the first programs funded by the Children's Bureau was the Webster School in Washington, D.C., which had a strong education component and provided comprehensive medical and social services for pregnant teenagers (although the medical and social services were not available on the premises). The evaluation of the program (Howard, 1968) used school records and follow-up interviews to analyze the 487 students enrolled there from 1963 to 1966. The control group were adolescents who had been referred to the Webster School but who decided not to enroll (thereby introducing a strong self-selection bias to the analysis). The evaluation con-

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eluded that the Webster School had effectively encouraged pregnant teenagers to continue their education. Although the Webster School is often briefly cited in discussions of model programs for pregnant teenagers, the evaluation never had much impact upon the field and has been largely forgotten. Instead, two other influential and thorough evaluations of Children's Bureau programs, those of the Young Mothers Program (YMP) at the Yale-New Haven Hospital (Klerman and Jeckel, 1973) and the Baltimore study (Furstenberg, 1976; Furstenberg, Brooks-Gunn, and Morgan, forthcoming) of a comprehensive care program for pregnant teenagers at Sinai Hospital have had the most impact. These two studies exemplify the strengths and limitations of the Children's Bureau evaluation efforts and provide a useful comparison to the more recent activities at the Office of Adolescent Pregnancy Programs. Both the New Haven and Baltimore programs served predominantly black pregnant teenagers in an urban setting in the mid1960s. As a result, neither of them had enough white adolescents to provide an adequate basis for comparison between the two subgroups of the population. Complicating this, the sample attrition rate among whites was much higher than among blacks. Service providers gave little thought to the problems of evaluation and made no attempt to structure their programs in order to enhance their evaluability. Indeed, both programs added the evaluations after the Children's Bureau issued requirements that any comprehensive care programs receiving funding have an ongoing evaluation. Probably the most important factor in the overall success of these evaluations was the decision to employ faculty members from Yale University (Lorraine Klerman and James Jeckel) for the New Haven evaluation and a graduate student from Columbia University (Frank Furstenberg) for Baltimore. The recruitment of these scholars was fortuitous not only because they possessed the necessary social science skills to undertake the investigations, but also because they quickly developed a professional interest and identification with these programs.3 After the initial funding for the service programs ended, these researchers continued working on the evaluations and sought additional support for a long-term follow-up study that had not been envisioned by the Children's

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Bureau.4 The other evaluations funded by the Children's Bureau were short-lived and much less rigorous than either the New Haven or Baltimore projects, which both developed sophisticated, long-term evaluations of the clients. Interestingly, if the New Haven or Baltimore evaluations had been done by one of the many nonuniversity research groups specializing in such work in Washington, D.C. today, the long-term evaluations probably would have been dropped; those firms undoubtedly would have abandoned the projects once the initial funding had ended.5 The strengths of both projects derive in large part from their broad scope and their long-term follow-up of clients. The original design of these studies, however, envisioned neither the final direction of those investigations nor their long-term orientation. The New Haven evaluation, for example, initially intended only to compare the outcomes of clients at the Young Mothers Program (YMP) with those of patients receiving services at the less coordinated and less comprehensive Inter-Agency Services (IAS) program at Hartford. By the end of the second research year, the investigators dropped the IAS program as a control group because the services received there resembled those obtained through the YMP. Consequently, a decision was made to draw a retrospective sample of pregnant girls who had received services at the YaleNew Haven Hospital just prior to the start of the Young Mothers Program. Unfortunately, the use of an earlier cohort of pregnant adolescents as a control proved to be equally problematic, as Klerman and Jeckel (1973) have acknowledged. Connecticut had just legalized the distribution of contraceptives for minors and those attending the YMP now had legal access to contraceptives (whereas those in the earlier cohort had not).6 Similarly, Furstenberg (1976) initially intended to evaluate the effectiveness of the Adolescent Family Clinic to which pregnant teenagers coming to Sinai Hospital had been randomly assigned. As the study progressed, however, his focus shifted to analyzing the consequences of early childbearing on the young mothers and their children, so he also drew a sample of their nonpregnant classmates. Although the control group in this instance was quite appropriate given the reorientation of the investigation, data comparable to that gathered at the first interview with the pregnant adolescents were unobtainable.

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In other words, both the New Haven and Baltimore evaluations were redesigned in order to answer new questions. Yet there were real limits to how much the original designs could be reoriented— especially in the case of the attempts by Klerman and Jeckel (1973) to find an appropriate control group. In addition, both projects discovered later that important clients or variables were missing altogether. The New Haven project did not collect any data on the pregnant girls who were married at the time of delivery and did not try to ascertain the actual income level of the family.7 On the other hand, Furstenberg (1976) later regretted that more effort had not been made initially to gather data from the husbands or boyfriends of the pregnant teenagers. From a statistical perspective, the initial analyses of the New Haven (Currie, Jeckel, and Klerman, 1972; Jeckel, Klerman, and Bancroft, 1973) and the Baltimore (Furstenberg, 1976) data were limited because they relied on a cross tabulation of the data. By considering only the relationship between any two variables at a time (or at best among three if a control variable was introduced), the investigators could not assess the relative importance of particular aspects of the clients' personal characteristics, their attitudes, or the services they received in leading to the successful outcomes of their pregnancies. In subsequent analyses, however, the researchers at both sites employed more appropriate and powerful multivariate statistical techniques. Klerman and Jeckel (1973) used path analysis to ascertain the relative importance of different factors in predicting childbearing, successful schooling, and economic independence at fifteen and twenty-six months postpartum. Similarly, but considerably later, Furstenberg, Brooks-Gunn, and Morgan (forthcoming) used path analysis to study the Baltimore patients after seventeen years.8 Thus, while the statistics employed limited initial work on pregnant adolescents in New Haven and Baltimore, the subsequent studies utilized more rigorous and sophisticated multivariate analyses. Most of the analyses of the New Haven or Baltimore data concentrated on finding statistically significant relationships between the various independent measures (such as current grade level or future ambitions) and the dependent variables (such as achieving economic self-sufficiency or succeeding in school). This is an important and useful approach to analyzing the data, but policymakers

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also need to know how changes in a particular variable will affect client outcomes and at what cost. For instance, policymakers are interested in knowing not only whether a relationship exists between schooling and economic self-sufficiency, but how much each additional unit of education enhances self-sufficiency and what the cost of that additional education is to the taxpayer in the short- and long-run. While the New Haven and Baltimore studies, in varying degrees, provide some information about the size of the effects, neither investigation tells us very much about the cost benefits of providing different types and amounts of services to the pregnant teenagers.9 Substantively, the results of the New Haven and Baltimore studies were quite similar, but the investigators sharply disagreed on their interpretations of some of the findings. Both studies strongly disagreed with Arthur Campbell's now classic statement that adolescent girls who have out-of-wedlock births face a bleak and highly determined future: The girl who has an illegitimate child at the age of 16 suddenly has 90 percent of her life's script written for her. She will probably drop out of school; even if someone else in her family helps to take care of the baby, she will probably not be able to find a steady job that pays enough to provide for herself and her child; she may feel impelled to marry someone she might not otherwise have chosen. Her life choices are few, and most of them are bad. Had she been able to delay the first child, her prospects might have been quite different assuming that she would have had the opportunities to continue her education, improve her vocational skills, find a job, marry someone she wanted to marry, and have a child when she and her husband were ready for it (Campbell, 1968: 238).

Instead, pregnant adolescents in New Haven and Baltimore experienced very diverse outcomes—especially several years after the birth of the child. As a group they were disadvantaged compared to their classmates who managed to avoid an early pregnancy, but they proved more resilient than anticipated and many of them succeeded in achieving self-sufficiency. The stereotype of adolescent mothers being chronically on welfare simply does not accurately portray their lives.10 The investigators found that while the comprehensive care pro-

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grams proved helpful in the short-run, they were not very effective in the long-run—especially because these programs were designed to help teenagers for only a few months after the birth of the child. They also agreed that the negative impact of early childbearing was particularly severe when another pregnancy quickly followed and that the second child often suffered more than the first one.11 While services for teenagers, especially those relating to keeping the pregnant girl in school were found to be beneficial, there was no indication that any particular type of special program performed more effectively than another.12 The New Haven study even found that pregnant adolescents attending the special Young Mothers Program (YMP) did not fare much better than those enrolled in the Inter-Agency Services (IAS) program at Hartford, which provided less comprehensive and less coordinated services. Consequently, Klerman and Jeckel admitted that: No single style or program emphasis is essential so long as the basic program components are provided by competent and motivated personnel. This study, therefore, does not conclude there is only one way to provide these basic services and offers no single program as a model (Klerman and Jeckel, 1973: 130).

Despite the lack of evidence that any specific set of services were essential for the well-being of pregnant teenagers, Eunice Shriver and the Coalition for School-Age Mothers continued to insist upon the need for mandating a set of core services in the 1975, 1978, 1981, and 1984 legislation.13 The New Haven and Baltimore studies also concluded that early marriages for these adolescents were inadvisable because these unions were so unstable, let to higher fertility, and discouraged continued school attendance. Klerman and Jeckel were particularly hostile to early adolescent marriages: Although many try to legitimize a pregnancy by marriage, early marriages have not proved stable. It therefore appears unwise to encourage teenagers to marry to legalize their sexual activity or their offspring. The rapid making and dissolution of a marriage, with all its legal and financial complications may be more of a psychic trauma to the mother and her child than an attempt to raise a child within her parent's home or independently, or an attempt to

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live unmarried in a temporary but loving relationship with a man . . . (Klermanand Jeckel, 1973: 4). Yet their analysis of the New Haven data (Klerman and Jeckel, 1973) does not provide the basis for such strong and unequivocal conclusions about the inadvisability of pregnant adolescents marrying. Because Klerman and Jeckel decided not to study the married adolescents enrolled in the YMP, they might have been more circumspect in speculating about the adverse effects of early marriage as they did not really address this issue directly in their research design. Although they stressed the instability of early marriages, they did not provide any convincing empirical evidence of this from the Young Mothers Program.14 While the Baltimore data (1976) did reveal that the majority of marriages became unstable by the fourth and fifth years, women with stable marriages fared much better economically and their children may have benefited as well. Indeed, in the analysis (Furstenberg, Brooks-Gunn, and Morgan, forthcoming) of the outcomes of the pregnant adolescents seventeen years later, a stable marriage was one of the best predictors of economic well-being.15 This discussion of adolescent marriages is too brief and too superficial to argue for either the advisability or inadvisability of encouraging pregnant teenagers to marry. Yet it does suggest that the strong explicit and implicit biases against early adolescent marriages in the New Haven and initial Baltimore studies inadvertently may have shaped the ways in which those data were interpreted and presented. Researchers with another perspective on teenage marriages might recast the results in a different direction. The area of strongest disagreement and the one that had the most serious impact on their differing policy recommendations was the question of whether most adolescents intended to have these children. Klerman and Jeckel (1973) argued that many if not most adolescents wanted to have the children while Furstenburg (1976) reached just the opposite conclusion.16 The division over this issue persisted and, as we have seen in Chapter Two, led to very different policy recommendations. Partly as a result of his pessimism about reducing initial pregnancies, Jeckel wanted all of the Title VI funds to go for care services for pregnant teenagers while Furstenberg argued that the funds shall be used for family planning

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services in order to prevent unintended adolescent pregnancies in the first place.17 Both Jeckel and Furstenberg participated in the debates over the adolescent pregnancy legislation in the late 1970s and early 1980s, thus the importance of the New Haven and Baltimore studies to policymakers was not based entirely, or perhaps even primarily, on just the quality of their evaluation. What made their work so effective and influential was the combination of producing quality evaluations and gaining access to the decision makers in Washington, D.C. through their close association with some of the more effective advocacy groups such as the Coalition for School-Age Mothers (Jeckel) and the Alan Guttmacher Institute (Furstenberg). Ironically, the two most respected and capable evaluators of programs funded by the Children's Bureau found themselves on opposite sides of the debates over the problems of teenage pregnancy in the 95th Congress.18 The Office of Adolescent Pregnancy Program's Evaluations of Care Programs As we discussed in Chapter Three of the Office of Adolescent Pregnancy Programs (OAPP) was created in 1978 and assigned responsibility for contracting a national study of adolescent pregnancy. Section VIII of the legislation establishing OAPP required that the Secretary of the Department of Health and Human Services (DHHS): Shall evaluate the effectiveness of existing programs relating to health, education, and public welfare, as they relate to this program and shall include suggestions as to the most effective means for reducing or eliminating unwanted adolescent pregnancies (JRB, 1981: 1-1).

Congress called for an indepth evaluation of the effectiveness of programs dealing with the problems of adolescent pregnancies and authorized up to $500,000 for that purpose. Yet OAPP ignored the broad intent of the Congressional legislation and focused only on

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service programs for pregnant teenagers and young mothers. OAPP also confined the study by using a surprisingly large proportion of the proposed evaluation contract to compile descriptive information about care programs throughout the United States. This shift in emphasis reflected not only OAPP's interest in a program directory as a first step in the establishment of a national network of service providers, but also the fear that a broader evaluation of all types of programs might conclude that family planning programs are a better investment of scarce resources than care programs for pregnant adolescents. OAPP was also concerned that a more detailed but critical assessment of existing care programs might lead to the same problems that the Westinghouse (1969) evaluation had created for Head Start.19 Replicating the earlier survey of the National Alliance Concerned with School-Age Parents (NACSAP) (Forbush and Jeckel, 1977), OAPP sent out questionnaires to care programs requesting information about the services provided, funding received, and clients served. OAPP would then instruct the contractor of the national evaluation to expand and analyze the results. The contractor was also to select from five to nine programs for a more indepth evaluation and make recommendations for improving policies dealing with pregnant teenagers. The competition for the contract seemed close with Triton and JRB initially receiving nearly identical overall ratings. Controversy arose, however, because according to the individual ratings by the four reviewers, Triton had originally received a higher score than JRB; but one of the two OAPP staff evaluators appears to have subsequently reversed their rating of the two firms and thus JRB won the contract (U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs, 1980b).20 The contract of about $120,000 (DHHS Contract Number 282-80-00700LG) was well below the $500,000 authorized by the legislation. This smaller amount reflects the fact that OAPP envisioned a much less ambitious evaluation than Congress had intended. OAPP had already mailed a six-page survey to 2,000 projects in the spring of 1980, so JRB only had to mail an additional 500 questionnaires in May and June of 1981. Altogether 1,340 surveys were returned and 941 of them were validated as meeting the criteria of providing at least 50 percent of OAPP's "core" services

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for pregnant teens. JRB produced a national directory of the service providers and deposited the computer tape of the replies to the questionnaires both with the Data Archives for Adolescent Pregnancy and the Inter-University Consortium for Political and Social Science Research. The estimated number of teens in need of services, the numbers served by the programs, the type of program organization, and the sources of funding were then tabulated by DHHS Region. JRB concluded that the necessary knowledge for solving the problems associated with adolescent pregnancy already existed, but that the organization and level of services required to assist these teenagers were still lacking.21 The JRB (1981) survey and analysis of service providers for pregnant teenagers is more comprehensive and more analytical than the one compiled by NACSAP five years earlier (Forbush and Jeckel, 1977). Yet its usefulness is limited because only about twothirds of the programs responded—thereby introducing a selfselection bias that may have affected the results. In addition, it is impossible to determine how representative the projects originally contacted by OAPP were because the mailinng lists had been assembled from a wide variety of sources. Undoubtedly smaller and less sophisticated projects, particularly in rural areas, are underrepresented. Finally, little use was made of the 245 additional responses to the JRB solicitation in the final analysis. Given these limitations, one should be cautious whenever using these data for analytical purposes.22 The JRB Report (1981) included five case studies of model programs—the Margaret Hudson Program for School-Age Parents, Tulsa, Okla.; the Johns Hopkins Center for Teenaged Parents and Their Infants, Baltimore, Md.; the Charles County Teenage Parenting Program, La Plata, Md.; Delaware Adolescent Pregnancy Program, Inc., Wilmington, Del.; the the Community Maternity Services, Albany, N.Y. The JRB analysis, based heavily upon secondary materials from the projects themselves rather than the collection of original data, provides interesting information on the type of the program, the clients served, and the costs of providing services. Unfortunately, the data collection procedures were not standardized and this limits comparison. Furthermore, these case studies did not have adequate control groups for ascertaining whether or not the program really effectively helped

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pregnant teenagers. Nevertheless, on the basis of the five case studies, JRB concluded that these programs are cost effective and have demonstrated their ability to improve significantly the lives of their teenage clients.23 Despite its methodological and conceptual shortcomings, the JRB Report (1981) provided a useful summary of trends in adolescent pregnancy and childbearing, compiled the most extensive national data on care programs, analyzed five model care programs, and produced a set of prioritized recommendations for ways to deal with adolescent pregnancy. Yet the JRB Report has had limited circulation because OAPP and DHHS were reluctant to release it—partly because the Department objected to one of the recommendations that seemed to criticize the Reagan Administration's cutbacks in human service programs such as WIC and CETA (JRB, 1981: 6–4). As a result, the evaluation of existing adolescent pregnancy programs mandated by Section VIII of the legislation has had little impact on either policy makers or other analysts in this field. The other major evaluation mandated under the Title VII legislation was an assessment of OAPP's activities. This program evaluation was to be conducted by an agency other than the one having primary administrative authority for the grant program. Therefore, in November 1978 the responsibility for this task was assigned to the Office of the Assistant Secretary for Planning and Evaluations (ASPE).24 OAPP protested against having the evaluation contract under the direction of ASPE, so the Office of Health Planning and Evaluation became a joint project manager for the evaluation. Finally, after securing funding from the Office of the Assistant Secretary for Health (OASH) because OAPP was unwilling to make any of its limited funds available for this undertaking, the Request for Proposal (RFP) for this evaluation was announced in July 1980, and awarded to the Urban Institute (Contract No. 100–80–124) three months later. However, the Urban Institute evaluation was not undertaken until nearly two years after the enactment of the legislation because of the late funding of local grantees that were to be evaluated by OAPP as well as that office's hostility against having an outside, independent entity evaluating not only the grantees, but OAPP itself. As a result, neither the information from the JRB Report (1981) nor the Urban Institute evaluation (Burt et al., 1984)

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provided much guidance for Congress when the legislation was scheduled for reauthorization in 1981,25 According to the contract, the Urban Institute was to develop, test, and implement a system for gathering basic, aggregate data on service delivery and short-term outcomes in each of the OAPP funded projects. Although no provisions were made for developing any control groups, the contractor was expected to evaluate the effectiveness of these programs using aggregate data obtained from the grantees.26 The Urban Institute was also to review and assess the coordination and management functions of OAPP and to make recommendations about how these could be improved. Just as the Urban Institute evaluation was finally getting underway, the Title VI Program was placed in a block grant and the new Director of OAPP, Marjory Mecklenburg, arrived in 1981. Although the Urban Institute contract could have been terminated because the original legislation was not being reauthorized, Mecklenburg decided to continue it in order to evaluate the effectiveness of the Title VI grantees in which the federal government had already invested for two years.27 OAPP now embraced the Urban Institute evaluation and not only assumed the funding, but even increased the total amount of the contract in order to make some improvements. Rather than just relying upon aggregate data as specified by ASPE in the original contract, OAPP persuaded the Urban Institute to use individual-level data whenever grantees could provide such information on a voluntary basis.28 OAPP also wanted an indepth analysis of the financial cost of the services provided by the grantees.29 The relationship between OAPP and the Urban Institute was generally harmonious and productive after Mecklenburg replaced Nix as the Director of OAPP.30 The Urban Institute competently designed and implemented detailed entry, service, and outcome forms for collecting aggregate data from twenty grantees at thirty individual projects (some grantees had more than one project site). Individual client data were assembled from twenty-three project sites and detailed financial information about the costs of services were obtained from eight projects. As the final report was being drafted, however, the Urban Institute argued that it did not have enough funds for the type of sophisticated statistical analysis that OAPP requested. Although

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the Urban Institute staff were experienced and skilled in designing questionnaires and implementing local data collection systems, they did not have all of the statistical expertise necessary for interpreting the results. Therefore, the Urban Institute sought an additional $30,000 from OAPP to complete the analysis. Because OAPP already had invested so heavily in this evaluation and seemed satisfied with the general direction of the evaluation, it came as a surprise when it refused any additional funds for the evaluation and suggested instead that money somehow be reallocated from other portions of the Urban Institute grant.31 This sudden unwillingness of OAPP to expend another $30,000 on evaluation was motivated less by a concern about the additional money (which was quite modest by federal standards), than by the growing reluctance of OAPP to fund the Urban Institute because conservative groups were attacking DHHS for continuing to fund liberal organizations.32 Although the Urban Institute finally managed to obtain the necessary funding from ASPE and the Ford Foundation to complete the statistical analysis, this incident seriously strained the working relationship between OAPP and the Urban Institute at the end of the contract period and minimized whatever influence OAPP might have had in trying to improve the statistical analysis in the final report.33 The Urban Institute evaluation produced several important contributions. Perhaps most important of all, from OAPP's perspective, the Urban Institute developed standardized forms for recording entry characteristics, services received, and outcome measures and trained the local grantees in how to use the forms. The Urban Institute also provided valuable technical assistance to the grantees in setting up an effective case management system. This was essential not only for the local management of the programs, but also for tracing clients in order to ensure that they received the comprehensive services intended by the Title VI legislation.34 Because the Title VI legislation mandated that OAPP funded projects had to provide all ten core services for pregnant teenagers and young mothers, development of standardized forms for collecting comparable information on the clients was made easier. The aggregate and individual-level data collected from the Title VI grantees represents the largest set of comparable data available from service providers today. Furthermore, the Urban Institute

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obtained information not only on the entry characteristics of the clients and the services they received within those projects, but also tried to obtain twelve and twenty-four month follow-up data (the sample attrition rate for these data were quite high because projects were not required to provide information on clients who had left the program).35 These data are machine-readable and were deposited with the OAPP funded Data Archive on Adolescent Pregnancy; thus, they can be reanalyzed or used as comparative data by other service providers or researchers.36 The Urban Institute also collected the most detailed and reliable information on the cost of various services for pregnant adolescents and young mothers. Whereas the proponents of increased federal support for care programs frequently cited a figure of $750 as the average total cost per client in a comprehensive program, the Urban Institute (Burt, et al., 1984: 96–129) found that the average cost for the actual package of services received during one year of participation by a pregnant adolescent was $3,892 (ranging from $2,982 to $4,650 across the eight projects analyzed).37 Of all services available, the four most expensive were prenatal care and delivery, public school attendance, child care, and financial assistance.38 Interestingly, private funding accounted for only 17 percent of the costs while federal money (either directly from OAPP or indirectly through other federal agencies) provided the bulk of support. The Urban Institute (Burt, et al., 1984) found that OAPP grantees concentrated on services relevant for pregnant adolescents and focused heavily on health services. Compared to other programs such as Project Redirection, the OAPP grantees devoted far less time and money in providing job training and vocational education. Clients who entered the projects as pregnant teenagers consistently received more services that those who entered as mothers. Rural projects delivered fewer services per client than urban ones and projects with better case management provided a greater diversity and more services per client than those that had no case management system. Unexpectedly no difference emerged in the kinds of services offered to the clients by projects that delivered all services on-site and those that referred clients elsewhere. Based on aggregate data and comparing the outcomes of clients to those of other adolescents nationally, projects did quite well in

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alleviating the immediate negative consequences of pregnancy and early childbearing, but were less successful in the long-run than anticipated. Teen parent outcomes at twelve and twenty-four months were quite satisfactory in reduced repeat pregnancies and continued education, but adolescents did not do well in either receiving job training or obtaining employment.39 While the overall outcome of clients seemed to indicate the advantage of attending one of these projects, surprisingly little relationship existed between the amount of services received and positive individual outcomes. The total service package received by individuals, for example, did not provide a consistently positive relationship to any of the outcome variables (although the individual services were positively related to particular outcome measures in some situations). The Urban Institute project provides some of the most detailed and interesting sets of comparable data on comprehensive adolescent pregnancy programs. Yet the quality of its analysis often leaves much to be desired. Rather than trying to study the followup data sequentially over time, the Urban Institute analyzed them cross-sectionally. Thus, sometimes the service that was being analyzed for its impact on an outcome variable, such as a repeat pregnancy, was actually delivered only after that outcome had already occurred.40 In addition, the analysis gives very little sense of the needs of the study population. Therefore, if an adolescent did not obtain a certain service, one cannot be certain whether she would have benefited from it, or whether that teenager did not really need that service. In other words, teenagers who received more services often did not fare better than those who received fewer services, but this may be because the adolescents with the poorest prognosis were provided the most services.41 Unlike the New Haven (Klerman and Jeckel, 1973) or the Baltimore (Furstenberg, 1976; Furstenberg, Brooks-Gunn, and Morgan, forthcoming) studies, the Urban Institute did not try to develop its own control groups, so any claims about the effectiveness of the OAPP funded programs should be seen as tentative speculations rather than as definitive conclusions.42 Finally, the multinomal logit analysis of the impact of these services frequently relies upon changes in the R2 values for assessing the effectiveness of the services rather than looking at the direction and strength of the standardized regression

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coefficients. Thus, the basic statistical techniques used in some of these analyses are inappropriate and cannot provide answers to the questions that were posed.43 Given the large amount of federal funds invested in this evaluation and the well-established social science reputation of the Urban Institute, the overall quality of the statistical analysis in the final report is very disheartening (Burt, et al., 1984). When the conceptual and statistical deficiencies present in a draft of the final report were brought to the attention of the agency responsible for supervising the contract (ASPE) it did not insist upon the necessary revisions. Instead, only a few cautionary notes were inserted throughout the text without remedying the defects.44 Unlike the JRB Report (1981), which was quickly and quietly shelved, the results of this investigation were publicized widely by both ASPE and the Urban Institute, but without adequate warning about its shortcomings. Martha Burt, the principal investigator, for instance, presented the results of this study before the Subcommittee on Health and the Environment (U.S., Congress, House, Committee on Energy and Commerce, 1984) but did not inform the members of its conceptual and methodological problems.45 Thus, the program evaluation of OAPP that initially seemed so promising turned out to be disappointing in its final moments both from a social science research perspective and as an example of the supervision of such activities by federal agencies. Congress expected that the local grantees funded by OAPP would evaluate their own programs. But as we have seen earlier, OAPP under Lulu Mae Nix did not encourage such evaluations and most OAPP funded projects were almost totally service oriented. The placement of the Title VI program into the Maternal and Child Health Block Grant in 1981, however, gave the new director, Marjory Mecklenburg, an opportunity to require evaluations. Because the Title VI program was not being reauthorized, OAPP considered canceling the FY1982 funding and returning the unexpended funds to the Treasury Department. OAPP finally decided to fund the Title VI grantees for one more year to facilitate the transition from categorical federal funding and to provide the Urban Institute sufficient time and data to complete its ongoing cross-project evaluation. Consistent with the direction of the new

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Title XX legislation, the Title VI grantees applying for FY1982 funds were required to include an evaluation component. OAPP cited the experiences of the Title VI grantees in developing their own evaluations as well as the additional information gained about the strengths and weaknesses of their delivery of services as reasons for continued funding. The results of the local evaluations of the Title VI grantees were very disappointing. Despite the new emphasis on project evaluations, most programs provided only simple descriptive statistics on their clients, services, and patient outcomes. Even those few projects that hired university-affiliated researchers failed to produce meaningful, rigorous evaluations. Many, if not most of the Title VI grantees apparently wrote their evaluations hastily in order to comply minimally with the grant requirements.46 OAPP might have tried to insist upon adequate evaluations by withholding funds from projects that failed to satisfy the evaluation requirement, but did not as it feared alienating the supporters of those grantees and attracting attention to problems in the overall program.47 Despite the disappointing results of the local evaluations from the Title VI FY1982 grantees, OAPP's other funding objectives were fulfilled more satisfactorily. The continuation of funding for one more year made it possible for the Urban Institute (Burt, et al., 1984) to complete its evaluation as some grantees could not provide adequate data from FY1981. If the Title VI grantees had not been funded for that additional year, it is likely that the Urban Institute evaluation itself either would have been discontinued or resulted in a much less useful report. The OAPP support for FY1982 also helped the grantees make the transition from Title VI funding to other sources of assistance. Of the twenty-nine service projects investigated in a follow-up study (Burt, et al., 1984: 154–158), twenty-eight (96 percent) continued to operate—although many reduced the size and scope of their operations. Seventeen of the projects applied for the new Title XX funding, but only eight were successful.48 Most of the grantees (72 percent) secured funding from the Maternal and Child Health Block Grant—the direct successor to the Title VI program. Almost one-third of the Title VI grantees received funding from private foundations, an unexpected result.

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The Title XX Adolescent Family Life Demonstration Projects legislation was intended to encourage and facilitate evaluations more intensely than the Title VI program, which under Lulu Mae Nix had become essentially just another federal service program. Like its predecessor, the Title XX legislation called for an overall evaluation of adolescent family life programs and allocated from 1 to 3 percent of total funds for that purpose.49 Unlike the earlier legislation, it did not require that the evaluation be supervised by an agency other than the one administering the grants program.50 The most innovative aspect of evaluation in the Title XX legislation focused on local grantees. Each project was required to expend from 1 to 5 percent of its OAPP funds for evaluation. This evaluation was to be conducted by an organization indpendent of the grantee providing the services; a working relationship had to be established with a college or university located in the grantee's state, which would assist in the monitoring and evaluating of the services.51 The Title XX legislation improved upon the Title VI program from an evaluation perspective, but it too imposed limitations on evaluation funding that adversely affected the quality of the work. The Adolescent family Life Program initially received an appropriation of $10 million, thus making only a maximum of $300,000 a year available for the cross-project evaluations. While this approximated the money spent on the Urban Institute evaluation, it was still too modest for the type of sophisticated evaluation envisioned—especially because projects now had the additional goal of preventing early sexual activity.52 Even more damaging was the ceiling set on funds for local evaluations. Most grantees could spend at a maximum only from $5,000 to $15,000 annually on evaluation—a sum much too small for any serious evaluation.53 In other words, the Title XX program had been designed as a demonstration and evaluation effort, but had seriously underestimated the costs of doing such work. Part of the problem arose from the fact that Congress wanted to create enough demonstration projects to place one or more in almost every state while at the same time keeping the overall cost of the program at a minimum. According to the Senate, one of the primary goals of the Adolescent Family Life Program was to:

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Provide the States with a workable model for similar comprehensive programs. Over one-half of the States have had no experience with an adolescent pregnancy program, and only four States have had a program for more than a year. Without a functioning demonstration project operating within a state, public officials will not have the opportunity to examine this innovative approach to a serious problem confronting State and local governments (U.S., Congress, Senate, Committee on Labor and Human Resources, 1981b: 9).

The desire to fund numerous demonstration models conflicted with the need to invest heavily in a few sites in order to evaluate them more rigorously. The decision to place demonstration projects throughout the United States nullified any attempt to do a more intensive and careful social science evaluation.54 The experience with the Urban Institute should have demonstrated the importance of soliciting the contractor for the crossproject evaluations immediately. The Urban Institute not only developed standardized reporting forms for the Title VI projects, but also trained program personnel in their usage and provided valuable technical assistance in other aspects of program management. Unfortunately, OAPP did not try to develop a cross-project evaluation immediately.55 Rather than design a multiple year evaluation to collect and analyze cross-project data in 1981 or 1982, OAPP waited until 1983 to hire the URSA Institute to provide technical assistance in developing the local evaluations under a one-year contract. A request for a national evaluation contract was not advertised until August 14, 1984—more than three years after the enactment of the Title XX legislation. Furthermore, only one firm submitted a bid for that contract and the panel of outside reviewers decided that their bid was technically unacceptable because of its very weak evaluation design.56 As a result, OAPP did not develop any cross-project evaluation during its first three years and thereby failed to provide the Congress and other policymakers with information about the relative effectiveness of different modes of service delivery. Local evaluations fared somewhat better under the Title XX legislation. Title XX was a demonstration program; applicants had to submit evaluation designs and were selected in part on the basis

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of the quality of those plans.57 Although the funds for local evaluations were limited, some of the projects developed effective analyses anyway. The requirement that the service providers work with colleges or universities in their own states brought project directors into contact with individuals who at least had some social science background and a strong commitment to evaluation. While most of the local projects did not have a well-designed evaluation plan or a sophisticated analysis of their data, a few are producing first-rate work. Nevertheless, for a program that was intended mainly as a demonstration and evaluation effort, the overall quality of the local evaluations is still unnecessarily weak and will not provide reliable guidance about the relative effectiveness of services within these programs.58 Thus, while the Title XX Adolescent Family Life Act provided a better framework for evaluating the programs than the Title VI legislation, the results so far do not reflect that difference. By failing to develop a national evaluation of the grantees, OAPP has not produced anything comparable to the Urban Institute evaluation (Burt, et al., 1984). Although the local evaluations from Title XX grantees represent an improvement over the Title VI project evaluations, overall neither are adequate from a social science perspective and the meager results do not justify the large expenditures of federal funds except as an indirect means of providing services for adolescents. Project Redirection At the same time that OAPP began to evaluate its comprehensive care programs for pregnant teenagers, the Ford Foundation and the U.S. Department of Labor set out to examine ways of helping pregnant adolescents and young mothers continue their education and improve their job opportunities by sponsoring Project Redirection in 1980 (which was intended to "redirect" the lives of these adolescents). Both the design and the evaluations (Levy and Grinker, 1983; Polit, et al., 1983) represent a very different approach to evaluation than the projects sponsored by either the Children's Bureau or OAPP. Project Redirection established demonstration programs in four

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cities—Boston, New York (Harlem), Phoenix, and Riverside, California59 Baseline interviews and twelve and twenty-four month follow-ups were conducted with the clients in each of the sites. One of the more interesting aspects of this evaluation design, compared to most others, was the pairing of these four cities with comparable communities that did not have a Project Redirection Program (Boston—Hartford; Harlem—Bedford-Stuyvesant; Phoenix—San Antonio; and Riverside—Fresno). Although the program operations differed, each site offered educational counseling, employability training, family planning services, referral to health care services, parenting education, personal counseling, life management education, and recreational activities. All of them also provided some innovative features such as drawing up an Individual Participation Plan (IPP) for each adolescent, establishing a linkage to the local Work Incentive Program (WIN), and providing a community mother for each teenager in the program. The adolescents eligible to participate in Project Redirection were all under eighteen years old, pregnant or a mother, without a high school diploma or GED, and receiving welfare or living in a welfare dependent family. All had been referred to Project Redirection through some community agency or by word-of-mouth from adolescents already in the sample. Therefore many had already received at least some services prior to participation in this experimental program. The matched control sample drawn from the other four cities was selected in an identical manner and its subjects were generally similar in personal characteristics to those participating in Project Redirection.60 Based upon a multivariate analysis (Polit, et al., 1983) of the matched sample and four-hundred Project Redirection teenagers at the end of twelve months, the program appears to be effective in getting teenagers to go back to school and helping them obtain job training and employment—especially for those who have never worked prior to entering the project. Project Redirection was less successful, however, in reducing unintended repeat pregnancies. Thus, OAPP (Burt, et al., 1984) projects seem to have done quite well in assisting teens to avoid repeat pregnancies but did not succeed in helping them find employment, while the reverse appears to be true in Project Redirection—probably reflecting in part the different orientations of the two programs. The initial short-

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term gains for Redirection adolescents at the twelve-month followup, unfortunately, were not sustained at twenty-four months. In addition to the statistical study of school and work experiences of teens in Project Redirection, an ethnographic study (Levy and Grinker, 1983) of adolescents in Riverside, Harlem, and Phoenix analyzed eighteen teenagers indepth to amplify the statistical impact study. The ethnographic study provided useful information about issues such as the tendency of teens to return to their mothers rather than their fathers during pregnancy and after delivery, the unwillingness of adolecent girls in the sample to marry the father of the child even though many of the fathers continued to be involved with the mother and baby, and the fact that while many teens found Project Redirection helpful, no particular aspect of the program was uniformly valued by the adolescents. The provision for a detailed ethnographic study of teens that complements the statistical study of their school and work patterns makes this an unusually creative and valuable effort. One of the virtues of Project Redirection is that it investigated the experimental program in four cities rather than just a single community as was the case in New Haven (Klerman and Jeckel, 1973) or Baltimore (Furstenberg, 1976). Because the operation of Project Redirection varied considerably from one site to another (including the provision of child care in Harlem and Phoenix, but not in Boston or Riverside), one would like to examine more closely the impact of the differences in the program on the outcomes of the adolescents. Unfortunately, the small sample size makes it impossible to discern the impact of program variations in the different settings. In addition, the large overlap between the communities and the ethnicity of the clients, makes it difficult to untangle the effects of one from the other. Because the service delivery differed significantly at each site, it is hard to decide exactly which particular aspects of the Project Redirection approach had the most positive impact on the teenagers.61 Deciding what contribution Project Redirection made to the well-being of the pregnant teenagers and young mothers was complicated because most teenagers were already receiving services from other agencies prior to enrolling in this experimental program. Indeed, 23.0 percent of the experimental group and 44.4 percent of the comparison group (Polit et al., 1983: 20) had already

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been in a teen parent program when the adolescents were interviewed for the baseline data.62 Further complicating the analysis was the fact that many of the teens in Project Redirection continued to obtain their services from other organizations while participating in this program.63 Although the evaluation team (Polit et al., 1983) considered the direct contribution of Project Redirection job training and family planning services, on most other services they simply investigated the effects of being in Project Redirection regardless of where the adolescents received those services. Furthermore, some of the most innovative aspects of Project Redirection, such as the role of the community mother, were not tested rigorously.64 Perhaps most glaring and disappointing from a policy perspective, is the lack of adequate information about the costs of Project Redirection. How much did it cost per client to enroll in Project Redirection and what monetary benefits resulted for the adolescent or the society? Were the slight reductions in subsequent pregnancies or the increased likelihood of returning to school justified by the amount of expenditure per adolescent? Many, if not most, adolescents in the program were already receiving extensive services prior to enrollment; how much does Project Redirection raise the overall costs of helping these pregnant teenagers? By failing to address the issue of cost, Project Redirection's evaluation seriously limits its usefulness to policymakers who must choose among alternative ways of dealing with adolescent pregnancy. Overall, Project Redirection is one of the more sophisticated and useful evaluations of comprehensive services for pregnant adolescents and young mothers. Certain elements of the program's operation are disappointing, such as the high rate of subsequent pregnancies and the limited effects of the program at the 24-month follow-up, yet Project Redirection provides a better model of program evaluation than OAPP's numerous demonstration projects that are inadequately funded for evaluation. Unfortunately, the recent decision of the Ford Foundation to reproduce Project Redirection in other sites without providing for further study of its effectiveness is misguided and short-sighted because the original evaluations (Levy and Grinker, 1983; Polit et al., 1983) still have not established exactly which aspects of the program should be duplicated and why.65

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Conclusion Program evaluations have become an integral and expected part of our social service system. Policymakers want and expect to be provided with studies that demonstrate the effectiveness of the programs they have funded. While few of these evaluations are really adequate from a rigorous social science perspective, the principle of commissioning and using them is now widely accepted. Program evaluation has played a particularly important role in the establishment and development of programs to provide care services for pregnant teenagers and young mothers. The Children's Bureau in the mid-1960s pioneered the inclusion of evaluations in its comprehensive care programs and the Office of Adolescent Pregnancy Programs (OAPP) has continued that tradition twenty years later. Yet few attempts have been made to assess the successes and failures of these undertakings as a means of improving the quality of future evaluations and increasing their usefulness for policymakers. Perhaps one of the important lessons is that serious evaluations are time-consuming and expensive. While projects should be encouraged to do some limited short-term evaluations on their own for monitoring and management purposes, the type of large and expensive evaluations necessary for ascertaining the long-term impact of these programs usually cannot be undertaken by any single program or group of service providers without considerable outside assistance. The attempts of the Title XX legislation to establish and evaluate more than fifty Adolescent Family Life Programs throughout the United States on a very limited evaluation budget is likely to fail and disappoint its sponsors once they look more closely at the results. A wiser and more efficient strategy would be to analyze a few of those projects in more depth by providing adequate funding for a proper social science evaluation. Project Redirection provides a better model for the type of evaluation needed in this field than the current practices of OAPP under the Title XX legislation. One of the shortcomings in the area of adolescent pregnancy programs today is that we still do not have adequate information about some very basic issues despite the millions of dollars that

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have been expended on research and evaluation. For example, notwithstanding the confidence of Eunice Shriver and Senator Edward Kennedy on exactly which set of core services should be required of all Title VI or Title XX grantees, little research supports their conclusions. Similarly, we know very little about the long-term advantages and disadvantages of going to an alternative school for pregnant adolescents rather than returning to a public school, because little attention has been paid to the impact of the different curriculum in those settings. Another lesson from the experiences of these programs is that evaluation often takes much longer than anticipated. Unfortunately, some of the most important results from these projects become apparent several years after the pregnant adolescent or young mother have left the program. Many of the results of the Baltimore study (Furstenberg, 1976; Furstenberg, Brooks-Gunn, and Morgan, forthcoming), for example, were published ten years after the Children's Bureau initiated its evaluation program. Similarly, the legislators in the 95th Congress did not foresee that the results of the Urban Institute (Burt et al., 1984) evaluation of the Title VI grantees would only be available six years later—well after the original program had ceased to exist as a separate, categorical program. Some of the delays in the evaluations are unavoidable given the difficulties in establishing and then assessing new programs, and the time needed to study the long-term impact of the services provided. Policymakers need to be more realistic about their expectations and be prepared, as of course they are, to act on imperfect knowledge of program effects. At the same time, knowing that results from evaluations are slow in appearing should stimulate agencies to design and implement evaluation programs as soon as possible. The failure of OAPP even to solicit a multi-year national evalution contract of its grantees until three years after the enactment of the Title XX legislation was a very unfortunate and unnecessary delay that has seriously limited the usefulness of that program. One of the major weaknesses in most evaluations of adolescent pregnancy care programs is the lack of an adequate control group. By having information only on the participants at a teen project, many studies cannot ascertain exactly what impact the program

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had on the well-being of the clients. In addition, some investigations (Klerman and Jeckel, 1973) selected a comparison group only to discover its inappropriateness afterwards. A few evaluations like the Baltimore study (Furstenberg, 1976) and Project Redirection (Polit et al., 1983) did develop appropriate control groups. In each case, the type of questions being asked determined the nature of the control group. This suggests that future evaluations will have to develop their own control groups to fit specific circumstances and particular questions instead of comparing the outcomes of their clients with overall national or regional data at the last minute. Another shortcoming in many evaluations is the use of very limited and often inappropriate statistical techniques for data analysis. Again, some of the investigations (Furstenberg, Brooks-Gunn, and Morgan, forthcoming; Polit et al., 1983) employ multivariate techniques effectively, but others continue to rely only on crosstabulating their data or misusing more sophisticated methods (Burt et al., 1984). The skills necessary in designing an appropriate questionnaire and obtaining cooperation from the projects and their clients in filling them differ from those needed to analyze the accumulated data. Most of the adolescent pregnancy programs are designed to provide prenatal and short-term postpartum care (usually six to eight months after delivery). Several of the evaluations (Klerman and Jeckel, 1973; Polit et al., 1985) point to the limitations of this approach because many short-term gains disappear a few years later. Other studies (Furstenberg, Brooks-Gunn, and Morgan, forthcoming), however, suggest that some of the services may have a more lasting impact on the adolescents than had been foreseen after just two or three years. The question of the short-term versus long-term impact of these services not only raises important substantive issues, but also calls for more longitudinal studies, which are inherently more expensive and less likely to provide immediate answers. Yet the general thrust of the findings from the best evaluations of the care projects to date is that we must design some of the future evaluations with a longer time perspective than just a twelve-month or twenty-four-month follow-up of clients. Our enthusiasm for the results from the latest evaluation should not blind us to the need for digesting and incorporating the infor-

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mation from earlier investigations. The sudden and unexpected discovery by Project Redirection (Polit et al., 1985) that some of the short-term gains from these programs may disappear at the twenty-four-month follow-up of clients only indicates that the principal investigators and their sponsors did not read the findings from earlier evaluations very closely (Klerman and Jeckel, 1973). Rather than always hoping that new findings will somehow provide a magic solution, we must reconcile ourselves to the complexity of the problems and accept the fact that most ameliorative programs will help, but not eliminate, the difficulties faced by pregnant adolescents and young mothers. We must build and improve upon earlier evaluations rather than ignoring them once the initial results have been released. One of the strengths of the Baltimore study (Furstenberg, 1976; Furstenberg, Brooks-Gunn, and Morgan, forthcoming) is that the researchers continued working on this project well after the original sponsors had lost interest. Similarly, rather than only trying to replicate Project Redirection at other sites, the Ford Foundation should be continuing to fund further evaluations of the original sample cohort and clients in the new programs. To facilitate the reanalysis of earlier evaluations, it is essential that other scholars have direct access to the original data. OAPP is to be commended for establishing and funding the Data Archive on Adolescent Pregnancy and Pregnancy Prevention, which collects and distributes machine-readable data not only from research projects but also from evaluations such as the Urban Institute study (Burt et al., 1984). In addition, OAPP requires all of its research grantees and evaluation contractors to deposit a machine-readable copy of their data within eighteen months of the completion of their project. Other federal agencies such as the Center for Population Research (CPR) of the National Institute of Child Health and Human Development (NICHD) should also institute a requirement in their grant awards that all appropriate data must be deposited with a public use archive. This makes it possible to redo data analysis relatively easily and inexpensively if new questions arise or if the quality of the statistical analysis is unsatisfactory. The almost total lack of interest in estimating the cost of services in these evaluations is deplorable from a policy perspective. With the notable exception of the JRB Report (1981) and the

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Urban Institute evaluation (Burt et al., 1984), most major studies (Klerman and Jeckel, 1973; Furstenberg, 1976; Furstenberg, Brooks-Gunn, and Morgan, forthcoming; Polit et al., 1983) have not estimated the cost of the different services provided to the adolescents. Instead, most investigators simply explore improvements in the clients irregardless of the cost of achieving those positive outcomes. Policymakers need accurate information on the costs of these programs for several reasons. At a minimum, they need to know how much it would cost to expand the current services to adolescents still in need of such services. Even more important is the development of cost-benefit ratios for the different services so that program directors can alter their operations in order to maximize the benefits to their clients. Finally, information about the costbenefit ratios of the services will assist policymakers in deciding whether limited funds should be set for prevention or care services. The quality of the evaluation is closely related to the quality of the social scientists involved in the analysis. One of the strengths of the Children's Bureau approach was its ability to attract first-rate scholars from universities such as Columbia and Yale. Similarly, the achievements of the Urban Institute (Burt et al., 1984) and Project Redirection (Polit et al., 1983; Levy and Grinker, 1983) evaluations are based on large part on the expertise of the social scientists participating in those studies. Therefore, one of the fundamental tasks of any evaluation is to recruit social scientists trained or experienced in evaluation research. The requirement in the Title XX legislation that all local evaluations must be conducted in conjunction with a college or university in that state is a step in the right direction. The involvement of scholars in evaluation projects has not, however, been problem free. Some university faculty members, for example, produced Title VI local evaluations for OAPP of such low quality that the individuals involved would be embarrassed if their colleagues ever read those reports. Professionals also often exaggerate the benefits of these programs and minimize any of the shortcomings. This is often evidenced in the executive summaries, which tend to be much more optimistic about the positive findings from the service programs than in the analysis and discussion of the data in the text. Sometimes personal biases, such as the strong

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negative view of marriage for pregnant adolescents, inadverently colors the way data are analyzed and presented. The relationship between social scientists and policymakers must improve in order to advnce the use of program evaluations in the future. Social scientists need to be careful not to lose sight of their professionalism and objectivity when they become program advocates—especially in summarizing the findings from their own research to policymakers. Whenever possible, the researcher should directly present his or her own results to the policymaker rather than having them interpreted and transmitted by some advocacy group. The social science profession as a whole should encourage more academic participation in program evaluations while at the same time monitor more closely the quality of the work produced. Whereas scholars have been very active and successful in maintaining high standards for academic publications, they too often remain surprisingly uncritical of the quality of the program evaluations—especially if the conclusions of the report generally match those of the reviewer. Policymakers also must foster a close, working partnership with the social scientists. They could encourage and support the involvement of the best social scientists in program evaluation by taking steps to facilitate academic bidding for evaluation contracts. Policymakers also need to take a more critical approach to these evaluations, instead of simply accepting or rejecting them depending upon the conclusions put forth. Instead of relying solely upon the interpretations of the social scientists involved in the investigation or their allies in the advocacy groups, policymakers should also consult with outside experts or hire and rely on staff members who are familiar with social science research. Congressional committees in particular must increase their oversight of program evaluations. Representative Henry Waxman and Senator Jeremiah Denton, for example, should have briefly set aside their differences on some policy issues and scrutinized more closely the quality and timing of the evaluations produced under the Title XX legislation. If officials in DHHS had known that the Congressional committees responsible for monitoring their activities might examine the quality of their evaluations from a social science perspective, ASPE probably would not have accepted the Urban Institute evaluation (Burt et al., 1984) without some major revisions.

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Evaluations are an essential part of developing effective social programs. As the public and some critics are increasingly questioning the appropriateness and usefulness of many of the programs growing out of the Great Society legislation in the 1960s, it will be necessary to provide much better evaluations than have been generally available so far. The evaluations of pregnancy care programs already have made significant contributions in how we perceive the problems associated with adolescent pregnancy and how we try In cope with them. Yet more and better evaluations of pregnancy care programs are needed in the future; this will require the reorientation and improvement of much of the ongoing evaluation work in this area today.

8 Conclusion

I will conclude by offering a few personal observations and reflections on the problem of adolescent pregnancy and government policy towards it. Early sexual activity, adolescent pregnancy, and teenage childbearing all pose serious and complex problems that defy simple explanations or solutions. However, neither adolescent pregnancy nor early childbearing represent a recent "epidemic", unprecedented in our history, as many policymakers and newspaper reporters seem to believe. As we have seen in Chapter Two, rates of adolescent pregnancy and childbearing peaked in the late 1950s. Recognizing this may calm the sense of panic that accompanies demands for quick and simple remedies. Clearly the problems associated with early sexual activity, adolescent pregnancy, abortion, and teenage childbearing, continue to plague us, with approximately one million teenagers becoming pregnant each year, 400,000 teenagers having abortions, and nearly half a million teenagers giving birth. Yet without a careful examination of the problem's history and of the efficacy of attempts to solve it in the past, we certainly will not make adequate use of pertinent information and are very likely to repeat noneffective panaceas. Early sexual activity has often been seen as a serious problem in America since colonial times, but only in the last twenty years has the federal government become involved in providing solutions. Answers developed to deal with adolescent pregnancy have changed from the early 1970s, in which the federal government focused almost exclusively on providing contraceptives for sexually active teenagers, to the 1980s, in which the Reagan Administration has emphasized postponing early sexual activity and helping pregnant teenagers and young mothers to raise their children. 211

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The question of whether or not the government should discourage sexual intercourse among young teenagers has now become a central issue. Most Americans believe that sexual intercourse is harmful to young teenagers and thirteen or fourteen-year-old boys and girls are too psychologically immature to handle a sexual relationship and are unprepared for the responsibilities of parenthood. Unfortunately, we have not yet developed any effective programs for persuading young teenagers to delay sexual activity. Most family life and sex education programs provide useful information to adolescents, but do not discourage early sexual activity or promote the use of contraceptives. These programs failed to slow the rapid increase in adolescent sexual activity during the 1970s—perhaps in part because many of their programs were not set up explicitly to discourage early intercourse. We must realize that the sexual behavior of children and adults in this country has been greatly influenced by the recent liberalization of laws and attitudes toward sex. As a result, it is unlikely that the recent increases in adolescent sexual activity will be reversed by a few special classes in family life and sex education in our schools. If we want to decrease adolescent sexual activity, we need to convey, in strong and unambiguous terms, that early sexual activity is simply inappropriate and unacceptable for young teenagers. Rather than clarifying the values of a thirteen or fourteen-year-old, as many counselors tried in the late 1960s and early 1970s, we need to impress upon our children that they should simply say no to early sexual activity the same way that we want them to say no to drugs and alcohol. Children should see human sexuality as a natural and normal part of life, but as inappropriate for young teenagers, They should be taught that abstinence is the surest and safest form of birth control available to them. Furthermore, perhaps the liberalization and exaltation of sex in our society has gone too far and our tolerance of explicit and exploitive sexual themes in television and movie programs designed for young teengers is misguided. Reversing today's trend toward early sexual activity will not be easy, but the presence of successful historical examples shows us that it can be done. Most of us would not approve of the harsh methods early nineteenth-century Americans used to reduce their high rates of premarital sexual activity; our alternative is to join together to change the climate of opinion in our country which now

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condones or even fosters sexual intercourse among young teenagers. It is encouraging to note that the levels of sexual activity among adolescent females has decreased slightly from 1979 to 1982—perhaps reflecting in part teenagers' increased awareness that early sexual activity is inappropriate and harmful (as well as the growing fear of herpes and AIDs). While we may not immediately eliminate much of the problem by trying to discourage young adolescents from early sexual activity, we must begin that effort now in order to begin altering societal sexual norms and practices. The United States has one of the highest rates of teenage pregnancy and childbearing among the developed countries today. One of the major reasons for this unfortunate distinction is that our sexually active adolescents do not use contraceptives as regularly or effectively as their counterparts in Canada or Western Europe (Jones et al., 1986). While most of us would prefer that young adolescents postpone sexual activity rather than rely on contraceptives to prevent pregnancies, it is unlikely that all teenagers will ever do so. Therefore, unless one is willing to accept our present high rates of adolescent pregnancy, abortions, and childbearing, we need to improve contraceptive use by sexually active adolescents. A small minority contend that the availability of family planning services for teenagers does not reduce adolescent pregnancy, but increases it by legitimizing early sexual activity. This viewpoint has gained a sympathetic audience among some powerful conservative senators and a few key individuals in the Reagan Administration— especially after Marjory Mecklenburg left as the Director of the Office of Family Planning Programs in 1985. The availability of contraceptives and federal support of family planning clinics may legitimize early sexual activity to some degree in the eyes of adolescents. Yet one should not exaggerate the effects of these factors on stimulating early sexual activity compared to other influences such as the widespread use of explicit sexual images and themes in advertising or in movies and television programs. Most teenagers are sexually active for more than six months before they ever come to a family planning clinic and therefore are not likely to have been hastened into it by any specific information or counseling received there. The conservatives who argue against providing any family planning programs for adolescents point to the small increase in teenage pregnancies dur-

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ing the last ten years, but they ignore the fact that the number of pregnancies per sexually active adolescent have declined. If contraceptives were not readily available, the rate of teenage pregnancy would be much higher. Some sexually active teenagers do use contraceptives effectively, but most employ them too late, use them only intermittently, or rely upon such ineffective methods as withdrawal. We need to educate sexually active adolescents to become more responsible users of contraceptives. Family life and sex education classes by themselves may not change behavior, but they can provide valuable information and assistance if we allow teachers to discuss birth control methods openly. If movies and television programs with teenage audiences insist on emphasizing sexual activity, they also should portray the actors trying to prevent unintended pregnancies. Similarly, if we continue to allow such blatant use of sex in advertising, then we should at least permit contraceptives to be advertised on network television. Perhaps most important of all, as responsible parents we must overcome our own discomfort and talk openly about sex and contraception with our children. Pretending that adolescent pregnancy is not a serious problem or hoping that someone else will inform teenagers about contraception is neither realistic nor fair to our children. Contraceptives generally are widely available in the United States, but young teenagers in particular often have difficulty obtaining them. Because some physicians are still unwilling to provide contraceptives to adolescents or charge too much for their services, we must maintain and expand the present system of federally funded family planning clinics. New ways of reaching adolescents, such as providing contraceptives through school-based health programs, need to be explored (Dryfoos, 1985). And while every effort should be made to involve parents whenever possible, some teenagers would undoubtedly stay away from family planning clinics if their parents had to be notified. The federal government should also undertake more systematic analyses of how to provide contraceptive information and devices more effectively. The Title X Family Planning legislation has earmarked funds for analyzing service delivery systems for over fifteen years; unfortunately much of that money was quietly di-

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verted to other tasks, such as supporting national and regional meetings for family planning providers. The small amount of real research on the delivery of family planning services that was done often suffered from the same types of shortcomings in research design and statistical analysis that we noted in regard to the evaluations of care programs for pregnant teenagers in Chapter Seven. Rather than endlessly debating the efficacy of providing contraceptives to teenagers in high school we should use federal research funds to investigate such programs. It is encouraging to note that the Reagan Administration has recently begun to use more of the Title X funds to investigate better ways of providing family planning services. Many individuals correctly point out that we do not have an ideal contraceptive for adolescents who tend to engage in sexual activity spontaneously and sporadically. We need to develop a more effective and useful contraceptive, but in the meantime sexually active teenagers should be encouraged to use birth control pills or condoms. Sexually active adolescents in western Europe are more effective in avoiding pregnancy than American teenagers in large part because a higher proportion of them use birth control pills and condoms. (Jones et al., 1986). Unfortunately, American women are reluctant to use birth control pills because they fear the medical side effects. While no definitive studies exist on the health risks of birth control pills for teenagers, the available evidence overwhelmingly suggests that the American public and many uninformed private physicians have greatly overestimated the negative consequences of using birth control pills (Hayes, 1987; Ory et al., 1983). The ill-fated attempt by the Reagan Administration to support its parental notification initiative by knowingly exaggerating the dangers of teenage use of birth control pills is only one example among many of how Americans have been misled about the medical risks associated with birth control pills. We should also encourage the use of condoms—especially for those teenagers just recently sexually active and those who engage in intercourse only intermittently. As the fear of sexually transmitted diseases grows, condoms are becoming a more attractive method of birth control for teenagers and adults. Because the use of

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condoms requires the active participation of the man, more emphasis should be placed on the male role. Men all too frequently act as if contraception is only a female responsibility. Arguing that improving the use of contraceptives by sexually active adolescents should be our primary emphasis is neither new nor surprising. The U.S. House Select Committee on Population (1978b) reached that same conclusion nearly a decade ago and the National Academy of Science Panel on Adolescent Pregnancy and Childbearing (Hayes, 1987) has recently reaffirmed it. Yet some individuals in Congress and in the Reagan Administration have neglected this important, basic insight. Instead of improving the provision of contraceptives to sexually active teenagers, they want to dismantle the present system of federally funded family planning clinics or at least discourage teenagers from using it. Rather than focusing on expanding the use of birth control pills among sexually active adolescents, they have devoted an inordinate amount of time and money to providing "natural" family planning, which almost everyone privately acknowledges is neither convenient nor effective. They also try to divert scarce federal dollars from family planning programs to services for pregant teenagers—a poor reallocation of funds as the cost of preventing an unintended pregnancy is much less than the expense of trying to alleviate the negative consequences of one. Therefore, we must reaffirm that the philosophy of providing safe and effective contraceptives to all sexually active teenagers underlies our policies for reducing the high rate of adolescent pregnancies in the United States. Pregnant teenagers, young mothers, and their children should have access to necessary medical and economic assistance and these young women should be given the opportunity to continue their education. Although teenagers who have children are disadvantaged compared to those who do not, many of the negative consequences of early childbearing can be alleviated, though not eliminated entirely, by providing adequate prenatal and postnatal care and long-term economic assistance. The primary responsibility for the financial support of the adolescent and the child rests with the young couple and their parents, but government assistance should be provided if necessary. The young father is an important and yet ignored partner in any adolescent pregnancy and should receive more attention. He should

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contribute financially to his new family even if he does not marry the mother. Although his monetary contribution may be small initially because of his youth and low wages, he must be forced, if necessary, to make at least token payments toward the care of his child. As the child grows up over the next eighteen years the financial contributions from the young father will increase as his earnings rise. Fathers should also be allowed and encouraged to participate in raising their child and they should not be discouraged indiscriminantly from marrying the young mother. Indeed, more attention needs to be paid to helping young couples stay together and raising their child in a secure and stimulating environment. Government programs can and do help pregnant adolescents and young mothers and their children, but we must discover which programs are the most effective in providing assistance. While former Senator Jeremiah Denton (R-AL) and the Reagan Administration are to be commended for sponsoring the Title XX Adolescent Family Life Program to develop and evaluate alternative service models for pregnant teenagers, their effort failed to produce the scientifically sound results mandated in the legislation (for the reasons stated in Chapter Seven). Rather than abandoning the effort to develop and test different ways of providing care, as some Democratic representatives are now suggesting, we should restructure the Title XX Adolescent Family Life Program and place it in the hands of administrators who are firmly committed to quality social science research and evaluation. Finally, historians and other social scientists must become more involved in the development, implementation, and evaluation of prevention and care programs. We need a broad, historical view of adolescent pregnancy instead of one that focuses on developments in the United States only during the last two or three years. Only by appreciating the influence of larger societal changes on today's adolescents and understanding the historical antecedents of current government policies can we hope to develop more effective ways of helping our children in the future.

Notes

Chapter 1 1. In the past, people were more likely to use the term "youth" instead of "adolescent" or "teenager." It encompassed individuals roughly from age fifteen to twenty-one or twenty-four. For purposes of this chapter, however, the terms "adolescent" and "teenager" will be used interchangeably and will refer to children between ages thirteen and nineteen. 2. Fogel (1986) has found that most of the relatively rapid upward movement in growth curves in America occurred before 1710. The height of Americans born in the eighteenth century increased at a very slow rate and, for those born in the nineteenth century, oscillated within a narrow band or even declined. These findings also reinforce our guess that the age of menarche in colonial America did not differ that much from that of nineteenth-century Americans. 3. We have little direct information on the age of menarche in colonial America because it was considered immodest for a woman to discuss this subject with anyone except her husband (Thompson, 1986). 4. There is some controversy over how difficult it was for peasants in western Europe to set up their own households. Hanawalt (1986) argues that the lack of inheritance or land often did not deter peasant marriages in medieval England because it was so simple for couples to marry. Nevertheless, she did not find many teenagers marrying in the fourteenth and fifteenth century. 5. The situation in the South differs; women there may have married at earlier ages. Walsh (1979), for example, found that girls in seventeenthcentury Maryland often married at earlier ages than their New England counterparts—especially if their parents had already died. As new studies of the demographic development of the South become available, we should be able to undertake a broader and more comprehensive analysis of this topic. For an introduction to the study of family life in the colonial South, see Lewis (1983), Rutman and Rutman (1984), or Smith (1980). 6. Parents in seventeenth-century New England probably exercised more control over the sexual and marital behavior of their children than did parents in the eighteenth or nineteenth century (Smith, 1973). 218

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7. Walsh (1979) suggests that colonists in seventeenth-century Maryland were less concerned with suppressing premarital sex than the Puritans in New England. No indictments for bridal pregnancy appear in any of the Maryland courts. 8. For a review of the relationship between religion and the family, see Moran and Vinovskis (1982). 9. Part of the decline in the Smith and Hindus (1975) index of premarital pregnancies in rural areas such as Hingham, Massachusetts in the nineteenth century may be the result of women from those communities going to Boston as unwed mothers because of the increased stigma attached to out-of-wedlock births (Hobson, 1980). While this factor may account for some of that decline, it is doubtful that very many unwed mothers from rural Massachusetts went to Boston for that purpose. 10. On the reform efforts in the antebellum period, see Rothman (1971). 11. On the role of religious revivals, see McLoughlin (1978). 12. Smith and Hindus (1975) found that after controlling for wealth, religion did not predict whether someone would become premaritally pregnant in Hingham, Massachusetts in 1767. They also stress the changes in the relations between parents and children in causing premarital pregnancies. Whenever greater ambiguity persists in parent-child relationships, premarital prenancies rise. As youth autonomy became more acceptable in the eighteenth century and incorporated into the social order in the early nineteenth century, premarital pregnancies declined. 13. On the development of common schools, see Kaestle and Vinovskis (1980). 14. Brumberg (1985) has done an important and interesting analysis of out-of-wedlock births among young girls in the late nineteenth century. She argues that by the late nineteenth century, American society had dropped its tolerance of any kind of premarital sexual activity and began to proscribe adolescent sexuality in particular.

Chapter 2 1. For details of the Carter Administration's adolescent pregnancy initiative, see the testimony by Julius P. Richmond, Assistant Secretary for Health, Department of Health, Education, and Welfare, and Surgeon General of the U.S. Public Health Service on March 2, 1978, before the Select Committee on Population (U.S. Congress, House, Select Committee on Population, 1978a: 496-509) 2. Though the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 passed in the final days of the 95th Congress, the bill only

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authorized the expenditure of funds, and did not provide any actual money; this function is the domain of the Appropriations Committees in both Houses. As we shall see in the next chapter, very little money was actually allocated for this legislation during the Carter Administration. 3. The Administration bill was introduced as the Adolescent Health, Services, and Pregnancy Prevention Act of 1978. In the House it was designated as H.R. 12146 and in the Senate as S. 2910. When it appeared that the bill would not pass the House, in part due to the lateness of its submission, it was attached in the Senate as an amendment to S. 2474, the Public Health Service Extension Act, portions of which had already passed the House. The House accepted the Senate's version during the October 14 to 15 conference, though a few changes were made. Therefore, technically, the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 simply became an amendment to S. 2474. For the sake of clarity as well as the way it was presented and debated throughout the session, however, the bill will always be referred to in this chapter as the Adolescent Health, Services, and Pregnancy Prevention Act of 1978. Later on the enacted measure was often referred to as the Title VI legislation. 4. The Adolescent Health, Services, and Pregnancy Prevention Bill was assigned jointly to the Subcommittee on Health and the Environment of the Interstate and Foreign Commerce Committee and the Select Committee on Education of the Committee on Education and Labor. However, the Select Committee on Population (which was an oversight committee only) held several days of hearings on the bill. Its members, several of whom sat on those standing committees, played an active role on the bill's behalf. As the Deputy Staff Director of the Select Committee on Population, I had the primary responsibility not only for initially drafting portions of our report dealing with adolescent pregnancy, but also for directly negotiating with the staff of the other House and Senate Committees on this bill. Much of my discussion draws very heavily on those experiences as well as on portions of our report on fertility and conception (U.S. Congress, House, Select Committee on Population, 1978b: 57–97). 5. See, for example, the statements by Senator Harrison A. Williams (D-NJ), Senator Edward M. Kennedy (D-MA), or Senator William D. Hathaway (D-ME) (U.S. Congress, Senate, Committee on Human Resources, 1978: 1, 41, 92). The sense of urgency and the "epidemic" nature of adolescent pregnancy is somewhat diminished by just reading the hearings (in part because the hearings are edited afterwards and the remarks of the participants are often toned down by themselves or their staff). Whenever questions were raised about the need for this legislation, a rare occurrence, the unprecendented "epidemic" aspects of the problem were stressed. Thus, when a Senator questioned the inadequate drafting of this

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legislation in the Committee mark-up, Senator Kennedy quickly admitted some of its shortcomings, but pressed for immediate action due to the need to deal with the "epidemic" of teenage pregnancies. As a result, the bill was passed by most congressmen without knowing many of the important details of the proposal, such as its proposed staffing. 6. Even the few witnesses who realized that the overall rate of adolescent childbearing had been steadily declining usually minimized this aspect and stressed the great increase in childbearing among adolescent girls under fifteen-years-old or emphasized the fact that the total number of teenage pregnancies had not declined very rapidly. 7. The estimate that 40 percent of female teenagers will become pregnant was a very startling statistic introduced by Frederick S. Jaffe, President of the Alan Guttmacher Institute, before the Select Committee on Population (U.S. Congress, House, Select Committee on Population, 1978a: 170, 551-552). Since then, using a different set of assumptions, Christopher Tietze has estimated that between 31 and 39 percent of teenage girls will become pregnant (1978). 8. For example, see Card and Wise (1978); McCarthy and Menken (1978); McLaughlin (1977); Moore and Waite (1977); Norton (1974). 9. The discussion that follows focuses on changes in adolescent childbearing for which we have accurate data. While we would like to have similar figures for trends in adolescent pregnancies rather than just births, it is impossible because we do not have good estimates of the number of illegal abortions for teenagers during the 1950s and 1960s. A large portion of adolescent pregnancies today result in induced legal abortions; presumably less of them would have ended in this manner when abortions were illegal and more difficult to obtain—especially for teenagers. Therefore, the decline in adolescent pregnancies from 1957-1977, probably would be less than that of adolescent births during that same period. 10. It should be pointed out that the participants in the debate on adolescent pregnancy only had access to the 1977 data. I have updated that information through 1983 because those figures are now available and readers of this volume may be interested in the more current data as well as those which policymakers in the 95th Congress used. Much of the information in this section of the essay is drawn from my initial staff draft of the report on fertility and contraception on this issue (U.S. Congress, House, Select Committee on Population, 1978b: 57–97). For useful summaries of recent statistics on adolescent pregnancy, see Moore and Burt (1982) and Moore, Wenk, and Hofferth (forthcoming). 11. Because such a relatively small percentage of adolescents under fifteen are already sexually active, it is difficult to target these children through traditional family planning programs or services for pregnant teen-

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agers. Therefore, if the plight of these youngest adolescents is indeed the justification for these additional expenditures, one might have expected that a large portion of the new money would be used for family life and sex education programs in the schools and the community. Yet most of the strongest proponents of this bill adamantly resisted any efforts to emphasize this aspect of the initiative. One cannot help but wonder if the growing problem of early childbearing among these very young adolescents was not used as a rationale to pass a bill really intended for their fifteen-, sixteen-, or seventeen-year-old counterparts. In other words, because the bill was rewritten by the Senate to aid mainly pregnant teenagers and because very few of the Senators would be likely to accept as given thirteen- or fourteenyear-old mothers, the bill does not really speak to the needs of these early adolescents. 12. Many of the members of the House criticized the bill because of the sloppy way in which it was drafted as well as the late date at which it was introduced. Nevertheless, the House went along with the Senate version of this bill in the final days of the 95th Congress because Congress was persuaded of the problem's urgency. 13. An earlier estimate by Arthur Campbell (cited in Baldwin, 1976: 8) argued that little change had occurred between 1960-64 and 1970-74 in the likelihood of premarital conceptions. Baldwin's pamphlet, which was widely reprinted in the appendices of these congressional hearings on adolescent pregnancy, is a very balanced summary and analysis of the trends. Unfortunately, very few congressmen or their staffs used this publication as the basis for their own analysis—even though Wendy Baldwin also testified at most of the hearings. Most of the congressmen and their staffs had already accepted the notion of an "epidemic" and almost all of the witnesses reinforced that idea—both in the hearings and in private meetings. One should also remember that congressmen are usually absent from hearings. Due to the heavy workload of the congressmen, usually with several overlapping committee meetings as well as other responsibilities, most of these hearings only had two or three congressmen present at any given time. 14. Unfortunately, we do not have very exact data on the proportion of teenage out-of-wedlock births that are put up for adoption. A frequently cited figure for adoptions in the 1950s is 90 percent, but there is little evidence to support that estimate. For a discussion of the adoption issue during these debates, see the testimony of Marjory Mecklenburg before the Select Committee on Population (U.S. Congress, House, Select Committee on Population, 1978a: 401–407). 15. Both the Administration spokespeople and the congressmen were aware of and concerned about the high cost of welfare payments to teen-

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age mothers and hoped that the adolescent pregnancy initiative would reduce that burden. If the Administration or the leaders of the bill in Congress had acknowledged the problem as one of a rapid increase in outof-wedlock births at a time when the overall rate and number of teenage pregnancies was declining, many of the more conservative congressmen probably would have advocated other solutions. 16. In general the range of witnesses who appeared before any of the four congressional committees on this issue was rather narrow. For example, almost everyone believed that the federal government should be more involved in funding programs either to prevent initial unintended adolescent pregnancies or help pregnant teenagers. 17. Throughout these hearings, the Administration spokespeople and the congressmen acknowledged their nervousness about asking for new programs in light of the recent "taxpayers' revolt" in California and elsewhere. For example, see the testimony of various Senators before the Senate Committee on Human Resources (U.S. Congress, Senate, Committee on Human Resources, 1978:44,95,97–98,102). 18. Though the Carter Administration was willing to specify that "a significant proportion" of the funds would go to primary prevention, they were unwilling to be more specific about the relative allocations, despite pressures from several congressmen to do so. The Carter Administration, despite its strong verbal support of family planning efforts, had recommended increases in the Title X program for family planning services that barely kept pace with the current rate of inflation. In fact, there is considerable evidence that the Carter Administration had a very limited commitment to expanding family planning services to address the needs of adolescents and low income women. The real pressure for family planning services came from certain congressmen in both the House and the Senate rather than the Administration. 19. From the very beginning, Senator Kennedy, with the assistance and urging of Eunice Shriver, had pushed for using these funds for helping pregnant teenagers. In 1975 he had introduced the National School-age Mother and Child Health Act, but it made little headway because the Secretary of HEW and the President opposed it. The proponents of that earlier bill saw the Carter adolescent pregnancy initiative as a wonderful opportunity to enact legislation similar to the National School-Age Mother and Child Health Act. Most of the participants in these debates saw the fight as one between wanting to help pregnant teenagers or allocating more money for family planning programs—which, as Senator Kennedy and others correctly pointed out, had already been authorized at relatively high levels. Yet the

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missing link in all of these efforts was the neglect of family life and sex education programs. Some people, including myself, felt that this bill provided a viable and unique vehicle for significantly expanding efforts in the areas of family life and sex education, especially important because the Carter Administration and the 95th Congress feared the political consequences of providing adequate funding for those programs only. For a detailed critique of the Adolescent Health, Services, and Pregnancy Prevention bill along these lines, see U.S. Congress, House, Select Committee on Population, 1978b: 89-97. 20. Jeckel's work was extensively cited by those who were opposed to more funding for family planning programs. His major scholarly article was widely circulated by the National Alliance Concerned with SchoolAge Parents (Jeckel, 1977). Although Eunice Shriver and others accepted Jeckel's work as authoritative, its analysis of contraceptive use by teenagers is inadequate. Jeckel was even unaware of or did not use much of the current literature on teenagers' likelihood to use contraceptives. For a critique of his position and those who relied upon it for their testimony, see the supplementary statement by Congressman James H. Scheuer, Chairman of the Select committee on Population and a member of the Subcommittee on Health and the Environment (U.S. Congress, House, Committee on Interstate and Foreign Commerce, 1978: 88-101). Congressman Scheuer and Congressman Anthony C. Beilenson, cochairman of the Select Committee on Population's task force on domestic fertility and contraception, were two of the most active and knowledgeable members in the House on the issue of adolescent pregnancy. They provided much of the leadership and direction for the Select Committee on Population on this matter. 21. Eunice Shriver was particularly successful in leaving that image with congressmen after having met with them individually. In private discussions with some of those members, Congressman Scheuer and I would often find them raising that issue and citing her talk with them as evidence. The idea that unmarried adolescent girls really want to have children, and therefore are not interested in family planning programs, may be true for a small, though significant proportion of them. Yet Eunice Shriver, James Jeckel, and the news media often implied that most pregnant teenagers wanted to become pregnant. This certainly is misleading and ignores the large amount of evidence that we have to the contrary. 22. Much of the data on sexual activity of teenagers are very poor and unreliable. One must exercise extreme caution when using any of this information. For a good critique of these studies, see Chilman, 1979. For a

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summary of what we do know about trends in sexual activity among teens, see Hayes (1987). 23. It is encouraging to see adolescents increasingly using effective methods of birth control such as the pill. Unfortunately, we do not have any definitive studies of the safety of birth control pills for teenagers; but there is a disturbing tendency in this country to exaggerate the actual health risks of the pill for adolescents compared to the risks associated with early pregnancy and childbearing (Hayes, 1987). 24. Testimony of Congressman James H. Scheuer (U.S. Congress, House, Committee on Interstate and Foreign Commerce, 1978: 90). 25. On the extent and need for contraceptive services for adolescents, see Dryfoos and Heisler, 1978. 26. The assumption by most congressmen who voted to shift the thrust of the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 to mainly helping pregnant teenagers was that the family planning programs had already received such high authorizations that they did not need additional funds. Although Congress approved the high authorizations, the money was not appropriated due to the lateness of the authorization process. However, the Carter Administration and the 95th Congress felt quite differently; the emphasis on balancing the budget meant that there would be only minor increases in family planning programs for FY1979. So, those individuals who had feared that the money granted for pregnant teenagers under the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 would be at the expense of family planning programs seem to have been at least partly correct. 27. On the development of federal and state family planning programs and the political problems associated with them, see Reed (1983), Dienes (1972), Vinovskis, Jones, and New (1974), and Gordon (1976). 28. When the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 was debated on the floor of the Senate as part of S. 2474 on September 29, 1978, Senator Jesse A. Helms offered an amendment that no contraceptive drugs or devices could be given to an unemancipated child under the age of sixteen unless the clinic notified the parent or guardian of this child of its intent to prescribe or dispense such drugs or devices. The managers of the bill accepted this without any object and Senator Kennedy called it a "worthwhile amendment" (U.S. Congress, 1978: S16597-S16600). The House, on the other hand, rejected similar language during consideration of the Title X family planning authorizations. As a result, the House conferees objected to this provision of the Adolescent Health, Services, and Pregnancy Prevention Act of 1978 and the Helms amend-

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ment was dropped. Many senators had objected to it earlier, but simply had not wanted to damage themselves politically by opposing it. For a more detailed discussion of the parental notification issue, see chapter four. 29. We still have not even eliminated the unintended pregnancies among married women. For example, Jane Menken estimated that as recently as 1970–72, nearly one-third of legitimate births were the result of unintended pregnancies (U.S. Congress, House, Select Committee on Population, 1978b: 251-255). 30. We do not really have any good estimates of the relative costs of adolescent childbearing over time. Even the figures for today are limited; work in this area has just begun. For some reasonable estimates for today, see Moore (1978). 31. It will be very interesting to analyze the reactions of Americans to any new federal or state programs in the 1980s as their own standard of living remains stationary or even declines. Part of the disillusionment with new federal and state programs of any kind may be related to the growing feeling among many Americans that their own future economic prospects seem bleak. 32. A large part of the impetus toward keeping children in school stems from the efforts in the 1960s to break the cycle of poverty, which policymakers were convinced doomed large segments of our population. Some of the early programs directed at adolescent pregnancy in the early 1960s were seen as part of that effort to assist disadvantaged individuals so that they would not repeat the cycle of poverty. 33. Though we now have a large number of estimates of the costs of early childbearing for today, virtually nothing is available for the 1950s and 1960s. When someone makes those calculations, it will be interesting to see if the social and economic disadvantages in the past were really less than today or whether we are only beginning to recognize the actual disadvantages associated with early childbearing. 34. Relatively little analysis has been done on the politics of abortion in the Congress. For some preliminary results, see Vinovskis (1980b). 35. For example, Senator William D. Hathaway stated the "the evidence supporting the need for legislation to prevent unwanted teenage pregnancies is overwhelming. I cannot emphasize enough our responsibility to recognize this problem, and to provide the help and support which our teenagers need as alternatives to abortion" (U.S. Congress, Senate, Committee on Human Resources, 1978: 93–94). 36. I suspect that most politicians as well as the public over-estimated the political strength of either the "pro-choice" or "pro-life" groups among the

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electorate. For a discussion of the politics of abortion, see Traugott and Vinovskis (1980); Jackson and Vinovskis (1983). 37. The data used in this publication generally are accurate; in fact, the general decline in fertility among older teenagers is graphed and discussed, and the stability of fertility among younger teenagers is acknowledged (Alan Guttmacher Institute, 1976: 12). Yet the overall image portrayed by this booklet and reinforced in other publications is that we have an "epidemic" of adolescent pregnancies. A few individuals, like Jacqueline R. Kasun, have attacked the booklet as inaccurate, but most people have either accepted its accuracy or have not acknowledged its misleading tone. One reason that this issue did not receive widespread attention during the hearings was because most witnesses chose to use this publication or at least not to disagree with it. Kasun's testimony, which was submitted after the hearings, and the rebuttal by Richard Lincoln are available in U.S. Congress, House, Select Committee on Population (1978a: 305-314, 318-322). 38. Throughout the debates on adolescent pregnancy, 11 Million Teenagers was widely used and quoted by the participants. One could almost predict the statistics that someone would use in these discussions, because everyone relied on the same source even though more up-to-date information was readily available. A fascinating study would be to analyze the impact of a publication such as this on the preparation of news stories and briefing papers. 39. Eunice Shriver and Robert Montague of the Joseph P. Kennedy, Jr., Foundation were instrumental in the creation of a coalition of groups interested in the passage of this bill. Though a few individuals, such as Janet Forbush of the National Alliance Concerned with School-Age Parents and Marjory Mecklenburg of the American Citizens Concerned for Life, provided much of the leadership, the coalition attracted a wide variety of groups ranging from Zero Population Growth to the National Council of Catholic Charities. This coalition, together with the personal efforts of Eunice Shriver, were extremely influential in rewriting the bill in close co-operation with Senator Kennedy and the other members of the Senate Human Resources Committee. 40. Though social historians have shown considerable interest in the political aspects of social developments, they have often approached these issues rather rigidly and simplistically. What is missing from most of these accounts is any awareness of the more subtle aspects of politics or the complexity of motivations involved. As a result, policymakers interested in understanding the historical antecendents of issues are more likely to find useful aids from groups such as the Brookings Institution than from

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social historians. For example, compare the analysis of day care politics and policies in Steinfel's work (1973) with the analysis of the politics of child care in Steiner's book (1976). Similarly, though Linda Gordon's book (1976) is very provocative, it certainly does not provide a very careful or balanced understanding of the complexities of efforts to develop family planning programs in this country. 41. An example of a widely cited but poorly executed analysis is Urban and Rural Systems Associates (1976). One of the problems in DHEW is that the people in charge of these programs often simply do not understand social science methodology well enough either to insist on careful research designs or to evaluate properly the results of these projects. 42. Even the work of Zelnik and Kantner, which is better than most in this weak field, leaves much to be desired in terms of sampling design or the use of sophisticated statistical techniques of analysis. 43. Whereas most congressmen are quite willing to fund more studies of the biological aspects of contraceptives, they are skeptical of any additional money for social science research. Many feel that social science research has not provided much new useful information, whereas biological research has led to better contraceptives. For a discussion of the value of social science research for population analysis, see U.S. Congress, House, Select Committee on Population, 1978b: 42-57. 44. Given the very limited funds allocated for purposes of evaluation, a large percentage of it goes into simply collecting the data rather than analyzing it. The Adolescent Health, Services, and Pregnancy Prevention Act of 1978 specifically allocated a larger percentage of the total funds for purposes of evaluating the success of different aspects of this initiative. 45. One of the most serious weaknesses in most studies of adolescent pregnancy has been that relatively little attention has been paid to the role of the adolescent's family. 46. On the life course approach to the study of the past, see Elder (1978a, 1978b); Vinovskis (1977, forthcoming); Hareven (1978a, 1978b). 47. Under certain assumptions, one can make some inferences about life course events from cross-sectional data, but the process is difficult and hazardous—particularly during periods of rapid change. For a discussion of these problems, see Vinovskis (1977); Baltes (1968). 48. For a discussion of the use of a life course approach for the study of adolescence and the changing orientation of the study of adolescence today, see Dragastin and Elder (1975). 49. An example of a study that has profitably employed a life course approach is the analysis of adolescent pregnancy by Furstenberg (1976); Furstenberg, Brooks-Gunn, and Morgan (forthcoming).

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50. Most studies of adolescence in the past have simply ignored the issue of adolescent pregnancy. For example, see Kelt (1977).

Chapter 3 1. On the changing role of the federal government in dealing with social problems, see Murray (1984), Steiner (1971,1976). 2. Despite the increased attention by the federal government to the problems of children, adolescents did not receive as much assistance as very young children. In large part this is due to the extraordinary efforts made to assist pre-school children through the Head Start Program (Zigler and Valentine, 1979). It also reflects the limited influence of the Children's Bureau on policy issues during the Johnson and Nixon Administrations (Steiner, 1976). The federal government in the early 1970s did encourage the development of programs for adolescent parents through the Inter-Agency Task Force on Comprehensive Programs for School-Age Parents established in 1971 by Eliot Richardson, the Secretary of DHEW. The lead agency responsible for this task force was the U.S. Office of Education, which provided support both for NACSAP and CECC. The latter organization ceased to exist on March 31, 1975, and therefore NACSAP, under the direction of Janet Forbush, became the major organization for those interested in adolescent parenting. 3. Lulu Mae Nix was appointed Director of the Office of Adolescent Pregnancy Programs by the Carter Administration and Marjory Mecklenburg replaced her following the election of Ronald Reagan. 4. For a discussion of the more general debates in the early 1970s over the issue of whether to make federal grants directly to local communities or to channel them through a state agency, see Steiner (1976). 5. Almost everyone testifying on the issue of care programs for adolescents accepted the idea that providing services would significantly improve the health and well-being of the mother and her child. One of the few exceptions was the testimony of Dr. Charles Lowe, Special Assistant for Child Health Affairs, Office of the Assistant Secretary for Health for DHEW in the Ford Administration, who asserted that "I find myself unaware of any study or combination of studies which provides convincing evidence that medical intervention during the pregnancy of a teenager predictably and unambiguously improves the health outcome of the infant" (U.S., Congress, Senate, Committee on Labor and Public Welfare, 1975: 35). 6. Whereas the location of the Office of Adolescent Pregnancy Pro-

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grams (OAPP) within the DHEW was to become a major issue during the debates on comparable legislation in the 95th Congress, it was not three years earlier—perhaps because no one really expected the "School-Age Mother and Child Health Act" of 1975 to pass. 7. The Ford Administration finally did sponsor a "Teenage Pregnancy Objective" initiative but only after the November election (U.S., Department of Health, Education, and Welfare, Office of Child Health Affairs, 1976). 8. Eunice Shriver (1977) criticized in October the expenditure of the new funds because "most of the $35 million will likely disappear into the sponge of existing HEW programs." Instead, she called for a new adolescent pregnancy initiative. "It is difficult to start new programs on short notice. Yet it seems to me that by FY79 there ought to be a clearly defined, family development program that includes specific support for comprehensive teenage pregnancy centers; an even greater effort on basic research in maternal, fetal and child health; and the beginning of essential clinical research in the same area." Califano (1977) replied: "I completely agree that a clearly defined initiative, including a youth and new family development program, should be included in the President's forthcoming budget and legislative program." 9. On Carter's problems with the abortion issue during the 1976 presidential campaign, see Vinovskis (1980a). 10. Several members of the Select Committee on Population, especially its Chairman James Scheuer (D-NY), strongly supported the Office of Population Affairs because they saw that agency as the one most committed to further expansion of federal domestic family planning programs. 11. Especially see the rebuttal by Congressman James Scheuer (D-NY) of the notion that most pregnant teenagers wanted to have a baby (U.S., Congress, House, Committee on Interstate and Foreign Commerce, 1978: 88-101). 12. Lulu Mae Nix closely allied herself with the coalition of groups and individuals led by Eunice Shriver and the Joseph P. Kennedy, Jr., Foundation. Advocates for using the funding for prevention, for example, expressed concern that she would allocate the funds only for care projects for pregnant teenagers. As a result, while her selection solidified the active support of those interested in helping pregnant teenagers for OAPP, it also diminished assistance from those who favored prevention. 13.The legislation establishing the Adolescent Pregnancy Program was Public Law 95–626—"The Health Services and Centers Amendments Act" of 1978. The sections dealing with adolescent pregnancy were VI, VII, and VIII.

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Under Title VI, OAPP makes direct grants to public and private non-profit organizations to provide a combination of health, education, and social services for pregnant adolescents, adolescent parents, their infants and families. Title VI also emphasizes services to prevent unwanted initial and repeat pregnancies. VII states that the Secretary will be responsible for coordinating all programs and policies relating to adolescent pregnancy at the Federal, State, and local levels. Title VIII requires an evaluative study of existing health, education, and welfare programs as they relate to the problem of adolescent pregnancy (U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs, 1981a). Hereafter, Title VI will be used when referring to the general legislation on Adolescent Pregnancy Programs, as this abbreviated notation was used by most participants. 14. Another problem for OAPP was that Lulu Mae Nix was not allowed to hire the individuals she wanted. Instead, most of the new employees transfered from other units within DHEW. Consequently, OAPP had to operate not only with a very reduced staff, but also with one that was not as trained or experienced in the area of adolescent pregnancy as one might have hoped. 15. Some of the regular DHEW employees in OAPP questioned the heavy reliance on the 25 to 30 outside consultants—especially because of the lack of communication between the consultants in the field and the regular staff in Washington nominally in charge of the programs. 16. The budget for FY1980 allowed OAPP twenty positions, but DHHS set the ceiling at fifteen. Interestingly, OAPP's recommendations for FY1980 called for a restoration of the twenty positions, but the job descriptions of the five additional positions did not call for anyone with expertise in evaluation (U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs, 1981a). 17. Although the Reagan Administration had placed Title VI in a block grant, DHHS was unofficially supportive of the Denton effort. Marjory Mecklenburg and some of her staff worked very closely with Senator Denton behind the scenes to design and modify his proposed legislation. As a one of the individuals involved during these negotiations at the staff level, I was a participant-observer and much of the following discussion of the enactment of the new Title XX legislation draws upon that experience. 18. From the very beginning, Senator Denton and his staff understood the controversial nature of the "findings and purposes" section of the legislation and of its probable effect on the opposition. Several individuals

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sympathetic to Denton's approach warned him about the negative consequences of using such language, but he ignored their advice because he wanted to placate the conservatives and because he had under-estimated the political strength of his opposition. 19. The specific details of the legislation are much more complex and can be followed more closely through the relevant issues of the Washington Memo. The final changes in the abortion clause, for example, were made at the Senate-House Conference Committee on the Omnibus Budget Reconciliation bill although the alterations that permitted the funding of projects such as the Johns Hopkins Program occurred much earlier.

Chapter 4 1. Considerable literature exists on the development of domestic family planning services during the 1960s. One of the best books detailing federal policies, especially in the area of international family planning assistance, is by Piotrow (1973). As her work does not contain much information about the judicial or state developments, one should consult Dienes (1972). The Reed (1983) volume continues to be very helpful. The Gordon (1976) book is a provocative account of developments in postWorld War II family planning, but is often unreliable and superficially researched compared to the works cited above. For an excellent review and critique of the historical studies of family planning, see Reed (1985). 2. One of the few congressmen who called for assistance for teenagers was Representative James H. Scheuer (D-NY). As he put it, "the desperate need for family planning by unmarried 14-, 15-, and 16-year-old girls in school is so transparently self-evident that it almost boggles the imagination to realize that nothing has been done. Virtually no leadership has come from the Federal Government" (U.S., Congress, Senate, Committee on Government Operations, 1967:18). 3. For example, at the hearings on the Title X reauthorization three years later (U.S., Congress, Senate, Committee on Labor and Public Welfare, 1973), few witnesses or policymakers dealt with the issue of teenage pregnancy. 4. For a more general discussion of the expansion of rights of minors, see Zimring (1982). An excellent analysis of the interplay of the courts and legislatures in regard to adolescent access to abortions can be found in Mnookin(1985). 5. Fearing the passage of a parental notification requirement, Representative Rogers tried to enact the Title X legislation on a suspension of the rules because this procedure does not allow any amendments from the floor. The Title X legislation, however, failed to receive the necessary

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two-thirds of the votes and therefore had to be reconsidered as a normal bill and face the likelihood of hostile amendments. 6. Several conservative and "pro-life" members of the Select Committee on Population, for example, who probably would have supported the Volkmer amendment on a roll call vote, remained conspicuously absent when the effort was made to muster support for a recorded vote. The "pro-life" forces on the House side were in disarray because Thea Baron, one of the more active and effective lobbyists for the National Right to Life Committee had just been removed. 7. Interestingly, Senator Richard Schweiker (R-PA) did not object to the deletion of the parental notification provision even though three years later, as Secretary of the Department of Health and Human Services (DHHS), he made the parental notification issue one of his top priorities. 8. Initially, the Administration proposed creating one block grant for these health programs. After further deliberation, it was decided to create four health block grants. The Title X program under H.R. 3224 would have been repealed and placed in the preventive block. 9. Representative Dannemeyer was expected to try to attach a parental notification requirement to the Title X legislation, but he was not present at the Subcommittee meeting to make his motion. 10. Marjory Mecklenburg, then the Acting Deputy Assistant for Population Affairs (DASPA) as well as the Director of the Office of Adolescent Pregnancy Programs in DHHS, was solicited by Dr. Edward Brandt, Jr., the Assistant Secretary for Health, DHHS, to draft language for that purpose. 11. William J. White remained openly hostile to the efforts of the Reagan Administration and received the distinguished public service award from the National Family Planning and Reproductive Health Association (NFPRHA Forum, May 1981: 11)—a group vigorously attacking the Administration's proposals in the area of family planning. Although conservatives both inside and outside DHHS demanded his removal, White remained in office for almost another year before being involuntarily transferred. Marjory Mecklenburg was selected to replace him at that time. Neither White nor Martin helped in the drafting of the parental notification regulations, despite the fact that they administered the Title X program. 12. Anderson was not acting alone in this area, but had quietly consulted other sympathetic policymakers in DHHS such as Marjory Mecklenburg. His memorandum listed a series of proposed changes in the Title X program including using the incomes of the families of the teenagers in determining whether the minor had to pay for the services. Although this was a secondary and largely ignored issue during the DHHS debates over

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parental notification, the final regulations did incorporate that suggestion (U.S., Federal Register, Feb. 22,1982). 13. The General Counsel had included a bizarre example of a possible interpretation unintended by Congress. The General Counsel argued that "a requirement that grantees require family consultation in cases where feasible would mean, among other things, that the children of a married couple would have to be involved in the couple's family planning decision" (del Real, 1981b). Mecklenburg's comments on the General Counsel's draft (Mecklenburg, 1981a) curtly dismissed that interpretation and no one raised it again as a serious interpretation of congressional intent during the parental notification debates. 14. Other "pro-life" activists considered Mecklenburg a moderate or liberal and distrusted her because she had always supported federal involvement in family planning programs. Her initial reaction was to support the encouragement of family involvement in the Title X program, but not to mandate parental notification because this did not appear to be the intent of the 1978 and 1981 legislation. Indeed, the initial drafts of her position that Ernest Peterson and I participated in developing (which never circulated outside her office), did not endorse a mandatory federal parental notification requirement. A few days later, however, she reconsidered her position and became a vigorous and consistent proponent of a parental notification requirement. 15. Dr. Brandt stated on November 9, that "I support the option recommended by Juan del Real in his memo of November 3, where we would rely upon State laws with respect to parental notification and consent." Sensing, however, that the Secretary would choose the required parental notification option, he advised that two additional points should be considered if that alternative were selected: There are instances where mental and/or physical harm could result from the notification of the patient's parent. There must be an opportunity for the patient and the physician to decide not to inform the parent when they believe it is in the best interest of the patient. Because of the issues of confidentiality and the protection of sensitive patient information, extensive documentation of the reasons for the decision not to inform the parent should not be required (Brandt, 1981). 16. Throughout DHHS's discussions on parental notification concern persisted that the internal memorandums would be leaked to opponents. As long as information stayed within a single agency such as the Office of Population Affairs (OPA), there was little danger of any leaks to the

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outside. But once documents circulated among agencies within DHHS for comments, the leadership assumed that the opposition would have access to the materials almost immediately. 17. Conservatives continually opposed continued funding for groups such as AGI, NFPRHA, and PPFA because federal funds indirectly helped to support organizations that tried to thwart the policies of the Reagan Administration. 18. Some members of the Reagan Administration expressed concern that the parental notification issue would seem capricious and totally impractical and would thereby jeopardize other domestic initiatives. After Secretary Schweiker presented a cogent if not totally convincing case for parental notification before the House Subcommittee on Health and the Environment, political worries within the Administration eased and there was less hesitancy about going ahead with the proposed regulations. 19. One of the problems facing the Reagan Administration was the lack of well-trained social scientists sympathetic to many of its domestic initiatives. As a result, DHHS often had to rely on staff or consultants who did not totally agree with important policies of the Administration. For example, while I shared Mecklenburg's commitment to the improvement of the quality of social science research available for analyzing policies in adolescent pregnancy and family planning, I personally did not agree with the decision to require mandatory parental notification. As a result, when the Office of Population Affairs (OPA) asked me to interpret and critically evaluate the social science studies used in the debates over parental notification, they did not want me to discuss these analyses publicly because it might become apparent that I did not share the Administration's enthusiasm for the proposed regulations. It should be pointed out that several of the individuals within DHHS who worked closely on the proposed regulations did not agree with the decision to mandate parental notification. Nevertheless, all of them carried out their assignments very professionally and did not attempt in any way to hinder the initiative's chances. In addition, Marjory Mecklenburg and others within DHHS listened willingly to any objections as long as those in disagreement kept their dissent within the confines of the office. 20. In general, the Administration was able to point out the methodological limitations in most of the social science studies cited by its opponents (U.S., Federal Register, Jan. 26, 1983: pp. 3600-3614). The weakest part of the Administration argument centered on the particular health risks faced by adolescents using prescription birth control methods. Responding to a request for a "brief update on the health consequences of using prescription methods of birth control—especially by teen-agers," Dr. Jeffrey Perlman, Chief of the Contraceptive Evaluation Branch of the

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National Institute for Child Health and Human Development (NICHD) responded that "this Institute never undertook a program to study the purportedly harmful effects of contraceptives specifically in adolescents because in our best medical judgment there are no problems of this nature deemed specific to younger women" (Perlman, 1982). Perlman went on to discuss the general health hazards of the pill and attached some relevant articles—but he did not seem to share the great concern about the medical dangers of pill use among adolescents that supposedly underlay the parental notification initiative. Thus, rather than seeing the parental notification effort as a response to information about the health risks of the pill for teenagers, it is more accurate to see it as a response to the Administration's concern about the rights and responsibilities of parents, which was rationalized as necessitated by medical considerations. 21. The Administration tried to counter with the slogan that the federal government has built a "Berlin Wall" between parents and their children, but this phrase did not come into wide use. Indeed, the "Squeal Rule" became so popular that even Administration officials sometimes used it privately when referring to the proposed regulations. 22. There was great concern that the proposed regulations could be dismissed by a judge if the large number of public comments were not carefully examined and considered. As a result, most of the energy of the Office of Population Affairs (OPA) was devoted to processing, assessing, and answering the public comments with much less attention to the problem of trying to influence public opinion. 23. One of the problems in dealing with the comments was that they were to be addressed to Marjory Mecklenburg at the Office of Population Affairs (OPA). When the unexpectedly large volume of mail arrived, it was impossible to separate out the public comments from the normal business mail sent to OPA without actually reading each letter. As a result, the regular business of OPA sometimes was delayed as the staff had great difficulty in keeping up with the flood of letters on parental notification. 24. The rationale for not tabulating the results was that "the numbers and nature of many of the comments makes a precise count of the comment 'for' and 'against' the proposed rule impossible. For example, while many comments opposed the proposed rules as requiring too much intervention in the family planning decisions of minors, others opposed them on the ground that they did not require enough . . . " (U.S., Federal Register, Jan. 26, 1983: 3601). In fact, it would not have been too difficult to tabulate the results even taking into consideration the complexities mentioned above. Yet the Office of Population Affairs (OPA) was

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more concerned about revealing the strength of the opposition against the proposed regulations than with having a more detailed statistical sense of the comments. 25. Both sides encouraged their supporters to send comments on the proposed regulations. Overall, it appears that the opponents of parental notification were much more effective in mobilizing their members to respond. 26. The CBS News/Wew York Times Poll also revealed that there were no major differences between Republicans and Democrats on this issue. Although the results of the poll were made public, few in the news media paid much attention to it. Instead, they continued to focus on the disproportionate number of commentators who opposed the regulations. Similarly, most social scientists (Kenney, Forrest, and Torres, 1982) analyzing the reactions to parental notification have failed to incorporate the results of the general public surveys into their analyses. While the CBS/New York Times Poll of adults did not have much effect on the news media or the public, it did play an important role in reassuring those within the Reagan Administration who favored the regulations. When someone pointed to the possible negative political implications of this controversy, supporters of the regulations cited the results of this poll to demonstrate that the public was much more evenly split than suggested by either the public comments on parental notification or the editorials in the newspapers. 27. At the December meeting within DHHS to decide on the final draft of the regulations, seven issues were considered: (1) whether to broaden the scope of the regulation to require notification for nonprescription methods; (2) whether the notification requirement should apply to the estimated 16,000 minors who receive the diaphragm from family planning clinics; (3) whether to require notification before clinics could provide prescription contraceptives to minors; (4) whether the notification requirement should be required when the family planning clinic provides prescription drugs for the treatment of venereal disease; (5) whether to broaden the exception to the notification requirement to include cases where it would result in mental harm to the minor by a parent or guardian; (6) whether to notify both parents; and (7) to what degree assurances were needed that the parents have been notified. 28. Simultaneously Secretary Schweiker announced that the Title X program would be moved out of the Bureau of Health Care Delivery and Assistance and to the Office of Population Affairs under Marjory Mecklenburg. This move consolidated Mecklenburg's control over Title X and was interpreted by family planning supporters as another indication of the

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hostility of the Reagan Administration to the program (Washington Memo, Jan. 19, 1983). 29. In both instances, each of the organizations filed a separate suit, but the federal judges consolidated the cases in each district. They refused the Administration's request, however, to consolidate all of the cases into one nationwide suit (Donovan, 1983). 30. The Title X Family Planning Program was located in the Bureau of Community Health Services under the direction of Edward Martin. Neither Martin nor White, both career civil servants, had a great deal of sympathy for the goals of the Reagan Administration and managed initially to protect the Title X program from major changes. 31. Ernest Peterson continued to work in this area as Mecklenburg's deputy and played a major role in running both the Title X and Title XX programs once control of them fell into Mecklenburg's hands. 32. In principle, as the acting DASPA she should have had a major role in the formulation of Title X policies, but Edward Martin in effect ignored her advice and suggestions as long as he retained direct control over the Title X program. His refusal to work with her was made possible by the continued reliance of Edward Brandt, the Assistant Secretary for Health, on the ideas and policies of Martin despite the increasing pressure from conservatives to introduce major changes in the Title X program. 33. When the conservatives finally succeeded in having William White ousted as the Director of the Office of Family Planning (OFF), few in DHHS imagined that his job would go to Mecklenburg. Yet her enhanced standing in the eyes of the conservatives as well as her own maneuverings within DHHS led to her appointment as White's successor. Moving the Title X program out of the Bureau of Community Health (BCH) and into the Office of Population Affairs (OPA) met with strong opposition within DHHS and outside from family planning supporters. Mecklenburg succeeded by convincing the conservatives that such a consolidation was essential if the Administration wanted to change the Title X program. 34. The National Family Planning and Reproductive Health Association (NFPRHA) had been receiving almost a half million dollars a year to hold conferences and maintain a network of family planning providers. The Administration wanted to deny any further funding because NFPRHA continued to oppose its policies. Therefore, Mecklenburg's efforts to restructure the service delivery improvement expenditures to emphasize applied social science research provided a convenient rationale for terminating the NFPRHA contract. Strong congressional support for NFPRHA, however, especially among House members such as Representative Conte, made it very difficult for DHHS to carry out its plans quickly.

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Chapter 5 1. I originally reanalyzed the AGI study (Torres, Forrest, and Eisman, 1980) as a consultant to DHHS. This assignment was part of the Administration's preparations for the anticipated legal battles over the proposed parental notification crisis. While the specific findings from my calculations have never been released by DHHS, they were used in the final notice of the regulations (U.S., Federal Register, Jan. 26, 1983: 3606). This chapter is based upon that earlier work but has been subsequently recalculated and rewritten. Therefore, neither DHHS nor any of its staff are in any way responsible for any errors in my reestimation of the AGI data or my conclusions. During the course of my own work on this issue for DHHS, I had the opportunity of meeting with the authors of the origial study at the AGI office in New York City. I am greatly indebted to Dr. Jacqueline Forrest and her research staff for their cooperation at that meeting as well as their subsequent assistance (Forrest, 1982). Although the AGI staff were extremely helpful by answering my specific questions and sharing some of their unpublished tables, they also are in no way accountable for my reinterpretations of their original study. 2. The Torres et al. study (1980) did not address the issue of the effects of requiring teens to pay for family planning services at clinics based upon their parental rather than personal incomes. Therefore, even though this issue is raised by the Administration's proposed parental notification regulation, I will not pursue this topic in this reanalysis of the Torres et al. study (1980). Readers who wish to pursue this matter further should consult a previous article by Torres (1976) on teenage incomes and clinic fees. 3. The decision to limit the patient survey to clinics serving at least 1,000 or more family planning patients in 1977 was based on the need to ensure a sufficient number of adolescents under eighteen attending (about 15 percent of the female patients are under eighteen) (Forrest, 1982). 4. After a meeting with the Alan Guttmacher Institute's research staff in New York on May 28, 1982, to discuss this analysis, Jacqueline Darroch Forrest, Director of Research and Planning, kindly provided me with some additional information on the biases that may have resulted from the exclusion of relatively small clinic sites (Forrest, 1982). Although her survey cannot directly answer the question of the extent to which minors in clinics serving more than 1,000 patients are similar to those with fewer clients, Forrest suggested that perhaps one could get some sense of the relationship by looking at the characteristics of patients

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in the larger clinics subdivided by whether or not they were located in a metropolitan or nonmetropolitan area. Forrest reports that there is little variation by metropolitan or nonmetropolitan area in the likelihood of parents knowing whether or not their children are going to a family planning clinic; but unmarried minors in nonmetropolitan areas are somewhat more apt to continue being sexually active without switching to another method of contraception—thus suggesting that the impact of the proposed parental notification requirement might be even higher if more patients from the smaller clinics, which are concentrated in the nonmetropolitan areas, were included. A bias may also be present due to the fact that the larger clinics are disproportionately located in hospitals or Planned Parenthood facilities rather than health departments. Yet when Forrest recalculated the distribution of responses to the question of whether or not parents knew their daughters were going to a clinic by weighting the answers according to the national distribution of the type of clinics, the differences were very small. In short, the reruns of the AGI survey data by metropolitan and nonmetropolitan area or by the type of clinic do not reveal any large differences. Nevertheless, because these distinctions are only a very rough and ultimately inadequate proxy for comparisons based upon the size of the clinics themselves, this issue awaits further testing. 5. The fact that the questionnaire assumed that unemancipated minors could not obtain medical contraceptives from private physicians is made clear in the unpublished paper by Torres and Eisman (1980), but it is not even mentioned in the published version (Torres, Forrest, and Eisman, 1980). As a result, almost none of the individuals who have cited the published article are aware that the AGI survey of teenagers asked questions about a very different set of options than those proposed by the Administration's parental notification regulations. The AGI (1982) comments on the proposed Administration parental notification regulations acknowledge that teens could go to a private physician, but minimize the potential importance of this alternative. 6. Torres and Eisman (1980) could not obtain direct information on the contraceptive rates of effectiveness by various methods from Zelnik and Kantner (1978a, 1980), but relied on those studies to make their own inferences. 7. Once some of these methodological limitations of the AGI impact study were raised, the authors shied away from using the precise figure of 33,000 pregnancies (AGI, 1982). They have not, however, publically disowned their earlier estimate and AGI and others continue to employ it. 8. When Torres and her colleagues (1980) estimated the impact of a parental notification requirement, they tried to use only those teens who

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were unmarried (they did not directly inquire about marital status, but only asked with whom the teenager was living). They did not inquire, however, whether the teenager already had experienced a live birth. 9. Another way of phrasing this would be to speak of person-months of exposure. Then we are simply estimating the reduction of personmonths due to the aging of the population. 10. Jacqueline Forrest again kindly provided me with more detailed tables on the reasons cited for not going to a private physician from AGIs other survey of teenagers (Chamie, Eisman, Forrest, Orr, and Torres, 1982). Of the 1,235 minors living with their parents who reported why they went to a family planning clinic rather than to a private physician, 58.2 percent cited the higher cost of the physician and 37.8 percent mentioned their fear that the doctor would notify their parents. If we eliminate the overlap in answers among those who both felt that a private physician was too expensive and might inform the parents, about one-fourth remain who preferred a family planning clinic for some other reason. In addition, a few of the teenagers saying that a private physician was too expensive were already paying $20 or more to attend a family planning clinic. As the cost of a visit to a private doctor is estimated at about $40 by Forrest, some teens may be able to cover the difference. Indeed, we also need to remember that teens only said that private physicians were too expensive, not that they absolutely could not afford to go. Furthermore, the smaller number of teens who insisted on not informing their parents and were willing to risk a future pregnancy either by not using any contraceptive method or a less effective one, probably felt sufficiently motivated to avoid informing their parents that some would try to pay for the visit by themselves or in conjunction with their boyfriends. Although the exact number of teenagers who would now be willing to go to a private physician is not clear, I suspect that it will be higher than the 10 percent who had gone to a private physician prior to their visit to the family planning clinic. 11. In estimating the net impact of a shift to another method of contraception, any previous reliance on lUDs was eliminated because they probably only would have been used by someone who had already experienced a live birth and therefore now would be considered legally emancipated in most states. 12. One study (Jones, Paul, and Westoff, 1980) questions the relationship between coital frequency and conception rates when contraceptives are used. But the authors point out that their reservation does not seem to apply in the case of younger respondents (under age twenty-five). Furthermore, the validity of the study is limited by the small sample size available for analysis. 13. The estimate of the extent of exemptions is based on a telephone

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survey of several Title X grantees undertaken by the Office of Population Affairs (OPA) and my review of the literature on the extent of prior child abuse and neglect among teenagers. The estimate of 8,000 to 9,000 exemptions is highly speculative and is intended only to demonstrate the need for making such an estimate rather than as a reliable guide for anticipating the actual number of teenagers who might be affected by it. In comments on the proposed regulations, AGI (1982) argues that "notification would probably almost never be waived." Whether or not clinic directors would exercise the option of waiving the proposed regulation cannot, of course, be predicted. Given the extent of child abuse among teenagers as well as the wording of the proposed regulation, however, one can envision that many clinic directors would have utilized this exemption provision. 14. In an earlier study, Torres (1978) found larger differences among clinics in the proportion of teenagers who said that their parents already knew of the visit. Because the clinics for that study were not randomly selected, the results of the more recent survey (Torres et al., 1980) should be more representative and reliable (Forrest, 1982). 15. I met with Jacqueline Forrest, Director of Research and Planning of AGI, and Aida Torres on May 28,1982, at the AGI office in New York City to discuss their study. At that time, we explored many of the limitations of the original study (Torres, Forrest, and Eisman, 1980) that have been discussed in this chapter. 16. Once the limitations of the Torres et al. study (1980) became apparent in early 1982, it was suggested that someone should be hired to redo the analysis or initiate a new investigation that might be completed in time to provide additional information to DHHS before the proposed regulations were enacted. Both of these suggestions were rejected by DHHS. In addition, when DHHS learned that someone in the Centers for Disease Control (CDC) already had launched a new study of the impact of the proposed regulations using the AGI study (Torres, Forrest, and Eisman, 1980) as a point of departure, it took immediate steps to have that investigation ended.

Chapter 6 1. Until very recently, historians have almost totally ignored the role of the father. For an introduction to this area of research, see Demos (1982) and Moran and Vinovskis (1986). 2. In Chapter One the debate over the existence of adolescence in colonial America was discussed more thoroughly. For a review of the issue of adolescence in the past, see Juster and Vinovskis (forthcoming).

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3. There is considerable debate over the changes in the status of women in colonial and nineteenth-century America. For an excellent overview, see Norton (1984). 4. For a useful introduction to the care of the poor in nineteenthcentury America, see Katz (1986). There is considerable disagreement over the motivations of the reformers trying to help the poor. Piven and Cloward (1971) point to the social control aspects of poor relief while Trattner (1984) emphasizes reformers' humanitarian motives. 5. See Chapter Three for a more detailed discussion of this legislation. 6. During the lengthy deliberations on adolescent pregnancy, parental involvement in childrearing was never emphasized by any of the congressmen, their staff, or the witnesses who appeared before the Select Committee on Population. Indeed, most participants simply did not think about the role of the father. 7. For an introduction to the type of programs that are being developed for adolescent fathers, see Elster and Hendricks (1986); Kahn and Bolton (1986); Klinman et al. (1986). For an analysis of what we know about the role of the adolescent father in the development of the child, see Elster and Lamb (1986). 8. The results from the Battelle study are very important because they show that most teenage marriages are still intact after five years (McLaughlin, Grady, Billy, Landale, and Winges, 1986). This study does not emphasize the stability of teenage marriages in the short-run, but others are using it to question the advisability of counseling most pregnant teenagers not to marry the father (Chase-Lansdale and Vinovskis, 1987). 9. Mecklenburg left OAPP in 1985 and it is still too early to know whether her successor, JoAnne Gasper, will continue this interest in the role of fathers. Preliminary indications suggest that OAPP will continue to pursue this topic.

Chapter 7 1. There are a few useful surveys (Klerman, 1979; JRB, 1981) of some of the evaluations, but none of them attempt to cover the entire twenty year period or focus on the more recent evaluations by the Office of Adolescent Pregnancy Programs. 2. Under the provisions of the Public Health Title X Family Planning Services Program, money was allocated for Service Delivery Improvement (SDI). Unfortunately, in the past much of that money was used only for conferences to disseminate information or to fund family planning advocates rather than to support rigorous evaluations of family planning programs. That situation, however, is changing. The Office of Population

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Affairs has reoriented the SDI program to focus more heavily on evaluations of the delivery of family planning services. 3. The process by which the scholars were "recruited" to these programs was rather haphazard and involved chance to a larger degree than planning. For an interesting account of how the Baltimore evaluation was initiated, see Furstenberg (1976: 20–23). 4. For example, when Furstenberg submitted a request for funding the follow-up study to the Children's Bureau in early 1969, it was initially uninterested, but then changed its mind and joined with the Population Council to fund the continuation study (Furstenberg, 1976: 25). The Commonwealth Fund supported the more recent follow-up of the Baltimore clients after seventeen years (Furstenberg, Brooks-Gunn, and Morgan forthcoming). 5. Some agencies in the Department of Health and Human Services (DHHS) have increasingly utilized nonacademically affiliated research firms to do program evaluation. While this may have beneficial short-term effects (as these firms are able to produce the reports quickly and respond to the concerns of policymakers), these groups cannot continue work once the initial funding has ended because the salaries of their employees, including the principal investigators, are entirely dependent upon outside funding. On the other hand, scholars in universities are often much slower in completing their projects and are usually unaware or uninterested in the policy implications of their research. However, they have the advantage of being supported to some degree by their institutions even when outside funding has ended for a particular project. 6. Klerman and Jeckel (1973) are careful to acknowledge that the lower rate of repeat pregnancies among YMP patients than among the control group may be to a large degree an artifact of the legalization of contraceptives for minors in Connecticut. Some policymakers, however, have not been as careful in interpreting these results and point to this study as evidence of the effectiveness of comprehensive care programs in reducing subsequent pregnancies. 7. The lack of direct information on the amount or source of income of these adolescents is a major shortcoming in the Klerman and Jeckel (1973) study. They decided not to ask such questions because they felt that it involved an invasion of privacy and that the results would be too inaccurate. Furstenberg (1976), on the other hand, and many other scholars have been willing and able to obtain reasonably accurate and useful information on the income of adolescents and their parents. 8. For discussions of alternative ways of analyzing such longitudinal data, see Tuma and Hannan (1984) or Mason and Fienberg (1985). 9. The analyses in the Baltimore study (Furstenberg, 1976; Fursten-

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berg, Brooks-Gunn, and Morgan, forthcoming) can tell us whether pregnant teenagers who went to the Edgar Allen Poe School, for example, did better than those who went to the regular schools, but the researchers do not try to consider what types or amounts of education adolescents received within that school. The New Haven study (Klerman and Jeckel, 1973) did try to measure the amounts of certain services received by the participants (such as the number of days attended at the special school or the number of individual social work interviews), but found no association between the amount of program contact and the likelihood of subsequent pregnancy or economic independence. But the measures employed in the New Haven analysis were few and there are questions about how they should be interpreted. In any case, neither the New Haven nor the Baltimore evaluations attempted to estimate the costs of providing such services to the individual adolescents. 10. Recent scholarship generally shows that there are few individuals remain permanently on welfare. Instead, most welfare recipients receive assistance for only a short period of time (Duncan, 1984). 11. While Klerman and Jeckel (1973) clearly understood the short-term limitations of the comprehensive care approach to helping pregnant teenagers, they did not convey the full implications of this finding to those drafting the federal legislation. Instead, the study made the usual calls for continued follow-up services and support, but with no real expectation that anyone would be willing to fund such programs. Furstenberg (1976) found that the short-term positive effects of services often disappeared after a few years, but in the follow-up of clients seventeen years later, it appears that those who attended the Edgar Allen Poe School did much better than those who did not (Furstenberg, BrooksGunn, and Morgan, forthcoming). 12. In the Baltimore study (Furstenberg, Brooks-Gunn, Morgan, forthcoming), the students who went to the special Edgar Allen Poe School did much better than those who continued in the regular public schools, but there was no other special educational program in their analysis that could be used as a comparison. Thus, we do not know exactly which elements the Edgar Allen Poe School made such a difference in the lives of its pupils. 13. Interestingly, while both Klerman and Jeckel were active in the National Alliance of Citizens for School-Age Parents (NACSAP) and had access to policymakers, they did not argue against mandating a particular set of core services, even though their own research suggested the need for flexibility and experimentation. 14. Klerman and Jeckel did not calculate the probability of marital disruption for those marrying after the birth of the child. Their data

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(Klerman and Jeckel, 1973: 103) at twenty-six-months postpartum, however, shows that of the forty-six adolescents who married sometime after delivery, only three of them (6.5 percent) were separated or divorced. Yet Klerman and Jeckel's (1973: 87) commented in the text that "these marriages began to dissolve quite early. One YMP girl reported being separated at the first interview, four at the second and one additional at the third." The rate of divorce or separation was higher in the IAS group (32.1 percent at twenty-six months postpartum), but Klerman and Jeckel did not explain why the adolescents in YMP were so much more successful in remaining married than their counterparts in IAS. 15. Furstenberg, Brooks-Gunn, and Morgan (forthcoming) argue that marriage by itself contributes little to a woman's chances for economic success because many of those marriages are quickly dissolved. Those who were married at the five year follow-up in 1972, however, were four times less likely to be on welfare in 1984 than those who had been previously or never married. In 1972, about one-third of the adolescents were never married, one-third formerly married, and one-third currently married (Furstenberg, Brooks-Gunn, and Morgan, forthcoming). 16. Klerman and Jeckel (1973) really did not have much evidence on the intentions of pregnant adolescents—especially because they did not interview a control group of teenagers who were sexually active but not pregnant or those who had become pregnant but had obtained an abortion. The Furstenberg (1976) analysis of the process of becoming pregnant is much more sophisticated and convincing than the Klerman and Jeckel (1973) study. In general, the Baltimore study is much better from a social science perspective than the New Haven investigation. 17. Furstenberg was not against funding comprehensive care services for pregnant teenagers. Indeed, he favored providing them with even more resources for them than either the Carter Administration or the 95th Congress. But given the scarcity of federal funds available for dealing with adolescent pregnancy, he urged that the money be targeted for prevention of initial, unintended pregnancies as this was a much more cost effective use of funds (U.S., Congress, House, Select Committee on Population, 1978a: 532-536). 18. Given the similarity of the New Haven and Baltimore studies in both their original intent and source of sponsorship, it is surprising how little interaction seems to have occurred between these investigations in terms of their work. Even when they disagreed upon the future direction of the Title VI legislation, they did not try to refute each others findings or conclusions, but were simply content to state their own positions. 19. Although few individuals in OAPP really knew the specifics of the Westinghouse evaluation of Head Start, several had heard about its initial

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negative impact upon that program and feared that a similar, unfavorable evaluation of care programs for pregnant teenagers would seriously jeopardize the program. For an account of the impact of the Westinghouse evaluation on Head Start, see Valentine and Zigler (1983). 20. The amazing thing about the competitive process was that the review panel judged submissions from several firms with well-established reputations in research and evaluation to be unacceptable. Indeed, of the nine proposals submitted, only Triton and JRB were considered acceptable from a technical viewpoint. 21. The preliminary drafts of the JRB Report did not contain much analysis. When Marjory Mecklenburg replaced Lulu Mae Nix as Director of OAPP in March 1981, however, she attempted to redirect the JRB contract to provide more analysis because the need for a simple directory of program providers had diminished. While JRB could not always comply with all of the proposed revisions, given the limited funds and time available, the researchers did make a concerted effort to meet the suggestions from OAPP and the final JRB Report (1981) is much more analytical and useful than the preliminary versions. 22. In fairness to JRB, it should be pointed out that delays in getting clearance from OMB to send out questionnaires made it very difficult for the firm to fulfill the terms of its contract. For a candid discussion of the limitations of the survey, see JRB (1981: Appendix B). 23. When Mecklenberg replaced Nix as Director of OAPP, an attempt was made to select a more interesting and useful set of model programs for evaluation, because some of the programs such as DAPI and the Johns Hopkins Project already had been analyzed. Due to the timetable of the contract, however, the earlier decisions of OAPP and JRB on which programs to use as case studies could not be reversed. 24. The Senate had suggested that the responsibility for overseeing the evaluation of the OAPP programs be given to the Center for Population Research (CPR) of the National Institute for Child Health and Human Development (NICHHD) as that "center has conducted the preponderance of federally supported social and behavioral research on adolescent pregnancy and childbearing and has developed great expertise in this subject area" (U.S., Congress, Senate, Committee on Human Resources, 1978b: 21). The Carter Administration, however, decided not to follow this suggestion and placed responsibility for the evaluation in ASPE. 25. When the 95th Congress had included funds for both a national study of existing adolescent pregnancy programs and an evaluation of the Office of Adolescent Pregnancy Programs, it assumed that the results from these studies would be available by the time the legislation came up for reauthorization three years later. In general, the Congress consistently

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under-estimated the length of time it would take DHHS to complete evaluations. 26. The decision by ASPE to require only the collection of aggregate data significantly reduced the type and quality of analyses that could be done. When OAPP later tried to change this part of the original contract, ASPE willingly agreed. 27. Because OAPP wanted to support the Title VI projects for another year despite the repeal of the old legislation, it seemed essential that the Urban Institute evaluation be extended as part of the rationale for continued funding of these service providers. 28. OAPP was unwilling to seek OMB clearance for mandating the participation of all Title VI grantees in the Urban Institute evaluation. Therefore, the Urban Institute had to obtain voluntary compliance from the grantees for the collection of both aggregate and individual level data. Although a few projects chose not to participate, most of them did cooperate and used the Urban Institute data system. 29. One of the surprising discoveries is that often evaluation projects did not include provision for assessing the costs of the services delivered. As a result, policymakers are handicapped because they cannot take into consideration the relative costs of providing different types and amounts of service. 30. Occasionally conflicts arose between the Urban Institute and OAPP. For example, OAPP strongly objected to the first draft of the evaluation on the functioning of the office itself as being unfair and incomplete. While the Urban Institute did not agree with all of OAPP's criticisms and thought some of them were just attempts to minimize any negative statements about the office, it sufficiently revised that draft so that the issue was resolved amicably. 31. OAPP did have a legitimate point that because the Urban Institute's original contract called for a detailed analysis of the data, no additional funding should have been necessary. The Urban Institute, however, pointed out that because OAPP requested the additional analysis of the individual level data, the evaluation cost much more than originally envisioned. 32. Originally, conservative groups had not focused on defunding liberal groups such as the Urban Institute and the Alan Guttmacher Institute. Therefore, OAPP went ahead with the funding of the original Urban Institute contract in mid-1981. As the conservatives increased their attacks on the funding of such groups in 1982 and 1983, however, OAPP became more reticent about its earlier support of the Urban Institute contract and did not want to be associated with any further increases in support. 33. As we shall see, when OAPP objected to many of the statistical

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procedures in the draft final report, neither ASPE nor the Urban Institute paid as much attention to these criticisms as OAPP's earlier suggestions because both groups felt that OAPP had already shirked its responsibility for this enterprise by refusing to provide the additional $30,000. 34. The importance of the Urban Institute to the development and functioning of the Title VI grantees was increased by the fact that OAPP did not have sufficient staff to monitor and assist the grantees. In addition, the close working relationship between the Urban Institute and OAPP after the arrival of Marjory Mecklenburg was reinforced by the hiring of Freya Sonenstein, one of the Urban Institute staff members, as the Director of OAPP's care programs. 35. The Urban Institute (Burt, et al., 1984: 68) acknowledged the problems introduced by sample attrition, but simply assumed that no distortion was introduced: "More often, however, the population of clients with sixmonth follow-up includes different individuals than the group with twelvemonth follow-up, or even than the group with delivery information. In speaking of patterns of change over time using these aggregate data, therefore, we are assuming that these different populations do not systematically vary on critical characteristics, e.g., one can reasonably expect to see the clients with reported pregnancy outcomes performing at six-month postpartum much like the clients reported in the six-month follow-up." Yet there are strong reasons for suspecting that those patients who stayed in the program at six-, twelve-, or twenty-four months were not identical to those who had dropped out of the program. OAPP suggested to the Urban Institute that at least some additional runs of the individual level data should be made to ascertain if the characteristics of those adolescents who stayed longer in the programs resembled those who left earlier, but that analysis was never made. 36. The name of the archive has been changed recently to the Data Archive on Adolescent Pregnancy and Pregnancy Prevention and is administered by the Sociometrics Corporation at Palo Alto, California. 37. The average cost for the actual package of services received during one year of participation by an already delivered, entering mother was considerably less, only about $2,000 (with a range from $900 to $2,900). 38. The sources of funding for these services varied greatly. Whereas 90 percent of the public school costs and vocational education came from local funds, all of the WIC and Food Stamp expenditures were federal. Nonproject federal funds also covered about 50 percent of the family planning services and 50 percent of the prenatal care and delivery. 39. The lack of success in OAPP funded projects in helping adolescents find employment led to one of the few minor changes in the Title XX legislation in 1984. Citing the findings from the Urban Institute Report

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(Burt, et al., 1984), Senator Jeremiah Denton (R-AL) amended the Title XX legislation to place more emphasis on vocational training (Congressional Record, June 29,1984: S8910). 40. The Urban Institute Report (Burt, et al., 1984: 65) states that "turning to the association of individual services with pregnancy outcomes, we must remember that some of the services were delivered to clients after the birth of their babies and may be in response to pregnancy outcomes as well as contributing to it. We stress that the coefficients describe associations between services and pregnancy outcomes, rather than exclusively causal relationships." While the cavaet is important, one wonders why the Urban Institute even bothered to present results that are so conceptually and methodologically meaningless and misleading. OAPP suggested instead that the Urban Institute rerun some subsets of the data so this problem might be eliminated or greatly minimized, but the Urban Institute did not follow this advice. 41. For example, the number of prenatal care visits was negatively associated with indices of a successful pregnancy outcome (Burt, et al., 1984: 52-53). 42. The Urban Institute did use the results from national surveys of adolescents or more specialized case studies (Klerman and Jeckel, 1973; Furstenberg, 1976). These comparisons, of course, were too gross to be of much value. The Urban Institute also ignored the suggestion that the comparisons might be more meaningful if it reran its own data to select those projects that most closely approximated the characteristics of the clients in the other studies it had used as controls. 43. Compared to the reanalysis of the Baltimore data (Furstenberg, Brooks-Gunn, and Morgan, forthcoming), the statistics used in the Urban Institute Report (Burt, et al., 1984) are very misleading and inappropriate even though they may seem quite sophisticated to the uninformed reader, as both studies used multivariate analyses. 44. The problems in the Urban Institute's draft final report were discussed at a meeting called by ASPE of the Technical Review Panel on February 3, 1984. Some of the most astute criticisms came from Bill Prossner and Tom Hertz, DHHS employees. ASPE probably did not insist on any major revisions was because the final report was scheduled to go to an outside printer in less than two weeks. While one can sympathesize with the efforts of the project officer to meet the scheduled deadlines for this report, a slight delay in the completion of this contract probably would have resulted in a much better final product. 45. Of coure, we might also fault the staff of the Subcommittee for not reading this important report more carefully and critically themselves.

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The difficulty, of course, is that Congressional staff have neither the time nor the expertise to go through the voluminous materials presented at the hearings. Therefore, outside scholars presenting materials to the Congress and the staff of DHHS have to assume more responsibility in making clear the strengths and weaknesses of such investigations. 46. This critique of the project evaluations is based upon a reading of all the final reports of the Title VI grantees. Indicative of the low quality of those reports is the fact OAPP could not even find a project report to exemplify the type of evaluation it wanted from the new Title XX projects. 47. One of the continuous dilemmas faced by OAPP was whether or not to stop funding a project because it had failed to provide an adequate evaluation. On the one hand, ending funding of a project on the basis of their inadequate evaluation would have sent a clear and forceful message to other grantees that their own evaluations had to be improved. However, OAPP was concerned that the resultant public dispute over funding might strengthen the position of those hostile to OAPP and politically damage the overall program. As a result, OAPP did not withhold funds from either the Title VI or Title XX projects because of inadequate evaluations. 48. It had been expected that the Title VI grantees would do very well in the competition for Title XX funds as they already used the Urban Institute forms and had developed evaluations for FY1982. The fact that less than 30 percent of the Title VI grantees tried and succeeded in receiving Title XX support reinforces the impression that most of them had not understood the new evaluation directives coming from OAPP for FY1982 or taken them very seriously. 49. Efforts were made to convince the Senate staff of the need for more evaluation money but they failed. One of the major reasons for the failure was because some of the Senate staff members involved had a very unrealistic notion of the cost of social science research in general. Indeed, the research grants were initially to be limited to $60,000 annually (including both direct and indirect costs). Only after considerable effort was the limit raised to $100,000 in direct costs. 50. In fact, because Senator Denton did not trust the other agencies in DHHS as much as he did OAPP under Mecklenburg, it was essential from his perspective that OAPP supervise its own evaluation. 51. The legislation allowed the Secretary to waive the five percent ceiling on local evaluations, but OAPP was unwilling to do so—party from a concern about the reaction of the Senate to the expenditure of a larger portion of the funds on evaluation than had been intended. 52. The cross-project evaluation of the prevention projects probably would be the most difficult and expensive to do because a standardized form similar to those for the care projects would have to be employed

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(due to the great diversity among the types prevention projects than care projects because the latter all had to provide the same basic set of core services). In addition, almost twice as many projects were funded under the Title XX legislation, thus making the project much larger than the Urban Institute study of the Title VI grantees. 53. There were ways creative projects could overcome some of the funding limitations. For example, by charging the data collection costs to administration and management rather than evaluation, more money would be available for the actual analysis of the data. 54. The legislation did not specifically mandate that numerous demonstration projects had to be funded, but OAPP chose to pursue this approach anyway as the intent of the legislation. However, neither the Congress nor OAPP understood clearly what was involved and needed in a comprehensive evaluation project and therefore saw little need to concentrate OAPP's limited resources on a few, well-designed evaluation projects. 55. OAPP never made the national evaluation of the Title XX projects a high priority. Other pressing issues, such as parental notification and defining the role of the Deputy Assistant Secretary for Population Affairs (DASPA), required so much time and energy that OAPP slighted evaluation of the Title XX grantees. 56. Perhaps because URSA was so active in working with the grantees and OAPP, other firms simply assumed that URSA would be likely to win the contract and therefore did not apply. One other firm did submit an application, but was disqualified as it had been delivered just after the deadline. As a member of the review panel, I was surprised and disappointed by the lack of a strong evaluation plan in the proposal and I voted with the other two reviewers not to endorse the application even though it meant that a national evaluation might be delayed by at least another three to six months. 57. Unfortunately, the quality of the evaluations in almost all of the Title XX applications was so poor that reviewers had little to choose from in terms of selecting projects with good evaluation designs. 58. The generally poor quality of local evaluations for these projects was evident at several evaluation meetings for the grantees in 1983 (Washington, D.C.) and 1984 (Leesburg, VA.) which I attended. While some projects, such as the one in Camden, N.J., had the beginnings of a strong evaluation, others were poorly designed and executed. For example, one prevention project tried to remedy its lack of pre-test information by asking participants during the post-test interview about the extent of their knowledge prior to enrolling in the program. 59. Originally Detroit was included as a fifth site, but was dropped because of management difficulties there.

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60. Unlike Klerman and Jeckel (1973), Project Redirection did not simply pick another community as a comparison without worrying about the similarity of characteristics of the clients. Instead, Project Redirection tried to match the personal characteristics of the teenagers as closely as possible so that the experimental and comparison groups are quite similar. 61. The expectations of the community mother, for example, varied from one site to another. Therefore, even when all four sites offered the same service, the method of service delivery could differ considerably. 62. In one of the comparison cities (San Antonio), for example, adolescents could receive services from one of the OAPP grantees that also provided integrated, comprehensive services for pregnant teens and young mothers. 63. Nearly all of the medical and most of the family planning services, for example, were obtained elsewhere (Polit et al., 1983: 35). 64. While some researchers did ask questions (Levy and Grinker, 1983) about the reactions of the clients to community mothers, they made no attempt to determine whether certain types of community mothers helped clients more effectively than others. 65. OAPP is currently funding part of the replication of Project Redirection, but has not succeeded in convincing its new grantee of the need for a more rigorous evaluation of the functioning of those projects.

References

Abert, J.G., ed. (1979). Program Evaluation at HEW: Research Versus Reality. 3 vols. New York: Marcel Dekker. Ager, J.W., P. Shea, and J. Agronow (1982). Method Discontinuance in Teenage Women: Implications for Teen Contraceptive Programs. In Pregnancy in Adolescence: Needs, Problems, and Management, eds. I.R. Stuart and C.F. Wells. New York: Van Nostrand Reinhold, 236-263. Alan Guttmacher Institute (AGI) (1982). Comments on the Proposed DHHS Regulations. April 2. —— (1976). 11 Million Teenagers: What Can be Done About the Epidemic of Adolescent Pregnancies in the United States. New York: Planned Parenthood Federation of America. Anderson, Carl A. (1981). Memorandum on Regulatory Reform of Title X—Voluntary Family Planning Programs. Sept. 17. Apter, D. (1980). "Serum Steroids and Pituitary Hormones in Female Puberty: A Partly Longitudinal Study." Clinical Endrocrinology 12, pp. 107-120. Aries, P. (1962). Centuries of Childhood: A Social History of Family Life. Trans. R. Baldick. New York: Vintage. Auwers, L. (1980). "Reading the Marks of the Past: Exploring Female Literary in Colonial Windsor, Connecticut." Historical Methods 4, pp. 204-214. Axtell, J. (1974). The School upon a Hill: Education and Society in Colonial New England. New Haven, Conn.: Yale Univ. Press. Baldwin, W.H. (1976). "Adolescent Pregnancy and Childbearing—Growing Concerns for Americans." Population Bulletin No. 31. Baltes, P.B. (1968). "Longitudinal and Cross-sectional Sequences in the Study of Age and Generation Effects." Human Development 11, pp. 145-171. Beales, R., Jr. (1975). "In Search of the Historical Child: Miniature Adulthood and Youth in Colonial New England." American Quarterly 27, pp. 379-398. Berg, B.J. (1978). The Remembered Gate: The Origins of American Femi254

References

255

nism: The Woman and the City, 1800-1860. New York: Oxford Univ. Press. Brandt, E.N., Jr. (1981). Comments on Revision of Family Planning Regulations. Nov. 9. Brenzel, B. (1980). "Domestication as Reform: A Study of the Socialization of Wayward Girls, 1856-1905." Harvard Educational Review 50, pp. 196–213. —— (1975). "Lancaster Industrial School for Girls: A Social Portrait of a Nineteenth-Century Reform School for Girls." Feminist Studies 3, pp. 40–53. Brumberg, J.J. (1985). " 'Ruined' Girls: Changing Community Responses to Illegitimacy in Upstate New York, 1890-1920." Journal of Social History 18, pp. 247-272. Brundtland, G.H., and L. Walloe. (1976) "Monarchal Age in Norway in the 19th Century: A Reevaluation of Historical Sources." Annals of Human Biology 3, pp. 363-374. Bullough, V., and M. Voight (1973). "Women, Menstruation, and Nineteenth Century Medicine." Bulletin of the History of Medicine 47, pp. 66-82. Burt, M.R, M.H. Kimmich, J. Goldmuntz, and F.L. Sonenstein (1984). "Helping Pregnant Adolescents: Outcomes and Costs of Service Delivery." Final Report on the Evaluation of Adolescent Pregnancy Programs. Urban Institute. Calhoun, A. (1960). A Social History of the American Family. 3 vols. New York: Barnes and Noble. Califano, J.A., Jr. (1977). Letter to Eunice K. Shriver. Campbell, A.A. (1968). "The Role of Family Planning in the Reduction of Poverty." Journal of Marriage and the Family 30, pp. 236-245. Card, J.J., and L.L. Wise (1978). "Teenage Mothers and Teenage Fathers: The Impact of Early Childbearing on the Parent's Personal and Professional Lives." Family Planning Perspectives 10, pp. 199205. Carey v. Population Services International (1977). 431 U.S. 678. Cath, S.H., A.R. Gurwitt, and J.M. Ross. (1982). Father and Child: Developmental and Clinical Perspectives. Boston: Little Brown. Center for Family Planning Program Development (1974). Family Planning, Contraception, and Voluntary Sterilization: An Analysis of Laws and Policies in the United States, Each State and Jurisdiction. Washington, D.C.: DHEW Publication No. 74-16001. Chambers, D.L. (1979). Making Fathers Pay: The Enforcement of Child Support. Chicago: Univ. of Chicago Press.

256

References

Chamie, M., S. Eisman, J.D. Forrest, M.T. Orr, and A. Torres (1982). "Factors Affecting Adolescents' Use of Family Planning Clinics." Family Planning Perspectives 14, pp. 126-139. Chase-Lansdale, L., and M.A. Vinovskis (1987). "Should Adolescent Mothers Be Discouraged from Marrying?" Public Interest 87, pp. 23-37. Chicago Tribune. Chilman, C.S. (1979). Adolescent Sexuality in a Changing American Society: Social and Psychological Perspectives. Washington, D.C.: DHEW Publications No. (NIH) 79–1426. Clarke, E.H. (1873). Sex Education; or, a Fair Chance for the Girls. Boston: J.R. Osgood. Commission on Population Growth and the American Future (1972). Population and the American Future: The Report of the Commission on Population Growth and the American Future. Washington, D.C.: U.S. Government Printing Office. Cott, N.F. (1977). The Bonds of Womanhood: "Women's Sphere" in New England, 1780–1835. New Haven, Conn.: Yale Univ. Press. Currie, J.B., J.F. Jeckel, and L.V. Klerman (1972). "Subsequent Pregnancies Among Teenage Mothers Enrolled in a Special Program." American Journal of Public Health 62, pp. 1606-1611. Cutright, P. (1972). "The Teenage Sexual Revolution and the Myth of an Abstinent Past." Family Planning Perspectives 4, pp. 24-31. Degler, C.N. (1980). At Odds: Women and the Family in America from the Revolution to the Present. New York: Oxford Univ. Press. del Real, J.A. (1981a). Memorandum to Secretary on Amendment of Title X, PHS Regulations to Provide for Parental Consent to Family Planning Services. Sept. 23. —– (1981b). Draft of DHHS Requirements Applicable to Projects for Family Planning Services. Oct. 2. — — ( 1 9 8 1 c ) Memorandum on Draft of Revision of Family Planning Regulations. Oct. 19. Demos, J. (1982). "The Changing Faces of Fatherhood: A New Exploration in American Family History." In Father and Child: Developmental and Clinical Perspectives. S.H. Cath, A.R. Gurwitt, and J.M. Ross, eds. Boston: Little Brown, pp. 425-445. —— (1974). "The American Family in Past Times." American Scholar 43, p. 428. —— (1970). A Little Commonwealth: Family Life in Plymouth Colony. New York: Oxford Univ. Press. Demos, J., and V. Demos. (1969). "Adolescence in Historical Perspective." Journal of Marriage and the Family 31, pp. 632-638.

References

257

Deseret News. Dienes, C.T. (1972). Law, Politics and Birth Control. Urbana, Ill.: Univ. of Illinois Press. Donovan, P. (1983). "Challenging the Teenage Regulations: The Legal Battle." Family Planning Perspectives 15, pp. 126-130. Dragastin, S.E., and G.H. Elder, Jr., eds. (1975). Adolescence in the Life Cycle. New York: Halsted Press. Dryfoos, J.G. (1985). "School-Based Health Clinics: A New Approach to Preventing Adolescent Pregnancy?" Family Planning Perspectives 17, pp. 70–75. Dryfoos, J.G., and T. Heisler (1978). "Contraceptive Services for Adolescents: An Overview." Family Planning Perspectives 10, pp. 223233. Duncan, G.J. (1984). Years of Poverty, Years of Plenty: The Changing Economic Fortunes of American Workers and Families. Ann Arbor, MI.: Institute for Social Research. Earle, A.M. (1895). Colonial Dames and Goodwives. Boston: MacMillan. Eisenstadt v. Baird (1972). 405 U.S. 438. Elder, G.H., Hr. (1978a). "Approaches to Social Change and the Family." In Turning Points: Historical and Sociological Essays on the Family, eds. J. Demos and S.S. Boocock. Chicago: Univ. of Chicago Press, pp. S1-S38. —— (1978b). "Family History and the Life Course." In Transitions: The Family and the Life Course in Historical Perspective, ed. T.K. Hareven. New York: Academic Press, pp. 17-64. —— (1975). "Age Differentiation and the Life Course." Annual Review of Sociology 1, pp. 165-190. Elster, A.B., and M.E. Lamb, eds. (1986). Adolescent Fatherhood. Hillsdale, N.J.: Lawrence Erlbaum. Elster, A.B., and L. Hendricks (1986). "Stresses and Coping Strategies of Adolescent Fathers." In Adolescent Fatherhood, eds. A.B. Elster, and M.E. Lamb. Hillsdale, N.J.: Lawrence Erlbaum, pp. 55-65. Erikson, K.T. (1966). Wayward Puritans: A Study in the Sociology of Deviance. New York: Wiley. Fogel, R. (1986). "Nutrition and the Decline in Mortality Since 1700: Some Additional Preliminary Findings." National Bureau of Economic Research Working Paper Series. No. 1802. Fogel, R., and S. Engerman (1974). Time on the Cross: The Economics of American Negro Slavery. 2 vols. Boston: Little Brown. Forbush, J.B., and J.F. Jeckel (1977). "A Survey of Programs for Pregnant Adolescents in the United States." Paper presented at APHA annual meeting. Washington, D.C.

258

References

Forrest, J.D. (1982). Letter to Maris A. Vinovskis. July 23. Forrest, J.D., A.I. Hermalin, and S.K. Henshaw (1981). "The Impact of Family Planning Clinic Programs on Adolescent Pregnancy." Family Planning Perspectives 13, pp. 109-116. Fox, G.L. (1981). "The Family's Role in Adolescent Sexual Behavior." In Teenage Pregnancy in a Family Context, ed. T. Ooms. Philadelphia: Temple Univ. Press, pp. 73–130. Fox, G.L., and J.K. Inazu (1980). "Patterns and Outcomes of MotherDaughter Communication About Sexuality." The Journal of Social Issues 36, pp. 7-29. Frisch, R.E. (1975). "Demographic Implications of the Biological Determinants of Female Fecundity." Social Biology 22, pp. 17-22. Frisch, R.E., and J.W. McArthur (1974). "Menstrual Cycles: Fatness as a Determinant of Minimum Weight Necessary for Their Maintenance or Onset." Science 435, pp. 949-951. Fuller, C.L. (1982). Memorandum for the Secretary of Health and Human Services. Feb. 8. Furstenberg, F.F. (1976). Unplanned Parenthood: The Social Consequences of Teenage Childbearing. New York: Free Press. —— (1971). "Birth Control Experience Among Pregnant Adolescents: The Process of Unplanned Parenthood." Social Problems 19, pp. 192-203. Furstenberg, F.F., Jr., Brooks-Gunn, J., and S. Phillip Morgan (forthcoming). Adolescent Mothers in Later Life. Cambridge: Cambridge Univ. Press. Furstenberg, F.F., Jr., R. Herceg-Baron, D. Mann, and J. Shea (1982). "Parental Involvement: Selling Family Planning Clinics Short." Family Planning Perspectives 14, pp. 140-144. Furstenberg, F.F., M. Markowitz, and L. Gordis (1971). "Birth Control Knowledge and Attitudes Among Unmarried Pregnant Adolescents." Journal of Marriage and the Family 30, pp. 34-42. Gordon, L. (1976). Woman's Body, Woman's Right: A Social History of Birth Control in America. New York: Grossman. Grady, W.R., M.B. Hirsh, N. Keen, and B. Vaughn (1981). Contraceptive Failure and Continuation Among Married Women in the United States, 1970-76. DHHS, NCHS Working Paper Series, No. 6. Graff, H.J. (1979). The Literacy Myth: Literacy and Social Structure in the Nineteenth-Century City. New York: Academic Press. Greven, P.J., Jr. (1970). Four Generations: Population, Land, and Family in Colonial Andover, Massachusetts, Ithaca, N.Y.: Cornell Univ. Press. Griswold v. Connecticut (1965). 381 U.S. 479.

References

259

Griswold, R.L. (1982). Family and Divorce in California, 1850-1890: Victorian Illusions and Everyday Realities. Albany, N.Y.: State University of New York. Grossberg, M. (1983). "Who Gets the Child? Custody, Guardianship, and the Rise of a Judicial Patriarchy in Nineteenth-Century America." Feminist Studies 9, pp. 235-260. Gutman, H., and R. Sutch (1976). "The Slave Family: Protected Agent of Capitalist Masters or Victim of the Slave Trade?" In Reckoning with Slavery, eds. P.A. David et al. New York: Oxford Univ. Press, pp. 94-162. Hajnal, J. (1965). "European Marriage Patterns in Perspective." In Population in History: Essays in Historical Demography, eds. D.V. Glass and D.E.C. Eversley. London: Aldine, pp. 101-143. Hall, D.D., ed. (1968). The Antinomian Controversy, 1636-1638: A Documentary History. Middletown, Conn.: Wesley an Univ. Press. Hanawalt, B.A. (1986). The Ties That Bound: Peasant Families in Medieval England. New York: Oxford Univ. Press. Hareven, T.K. (1978a). "Introduction: The Historical Study of the Life Course." In Transitions: The Family and the Life Course in Historical Perspective, ed. T.K. Hareven. New York: Academic Press, pp. 1-16. —— (1978b). "Cycles, Courses and Cohorts: Reflections on Theoretical and Methodological Approaches to the Historical Study of Family Development." Journal of Social History 12, pp. 97-109. —— , ed. (1978c). Transitions: The Family and the Life Course in Historical Perspective. New York: Academic Press. Hareven, T.K., and M.A. Vinovskis (1978). "Patterns of Childbearing in Late Nineteenth-Century America: The Determinants of Marital Fertility in Five Massachusetts Towns in 1880." In Family and Population in Nineteenth-Century America, eds. T.K. Hareven and M.A. Vinovskis. Princeton, N.J.: Princeton Univ. Press, pp. 85125. —— (1975). "Marital Fertility, Ethnicity, and Occupation in Urban Families: An Analysis of South Boston and the South End in 1880. "Journal of Social History 9, pp. 69-93. Hayes, C., ed. (1987). Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Vol. I. Washington, D.C.: National Academy Press. Herceg-Baron, R., and F.F. Furstenberg, Jr. (1982). "Adolescent Contraceptive Use: The Impact of Family Support Systems." In Childbearing Decision: Fertility Attitudes and Behavior, ed. G.L. Fox. Beverly Hills, Calif.: Sage Publications, pp. 125-144.

260

References

Miner, N.R. (1975). "Adolescence in Eighteenth-Century America." History of Childhood Quarterly 3, pp. 253-280. Hobson, B. (1981). "Sex and the Marketplace: Prostitution in an American City, Boston, 1820-1880." Unpublished Ph.D. thesis. Boston University. —— (1980). "A Wolf in Gentleman's Garb: Sources of a Parable of Seduction and Betrayal. Unpublished Paper. Howard, M. (1968). Multi-Service Programs for Pregnant School Girls. Washington, D.C.: Children's Bureau. Jackson, J., and M.A. Vinovskis (1983). "Public Opinion, Elections, and the 'Single-Issue' " In The Abortion Dispute and the American System, ed. G.Y. Steiner. Washington, D.C.: Brookings Institution, pp. 64-81. Jeckel, J.F. (1977). "Primary or Secondary Prevention of Adolescent Pregnancies?" Journal of School Health 47, pp. 457–461. Jeckel, J.F., J.T. Harrison, D.R.E. Bancroft, N.C. Tyler, and L.V. Klerman (1975). "A Comparison of the Health of Index and Subsequent Babies Born to School Age Mothers." American Journal of Public Health 65, pp. 370-374. Jeckel, J.F., L.V. Klerman, and D.R.E. Bancroft (1973). "Factors Associated with Rapid Subsequent Pregnancies Among School-Age Mothers." American Journal of Public Health 63, pp. 769-773. Johnson, F.E. (1974). "Control of Age at Menarche." Human Biology 46, pp. 159-171. Jones, A.H. (1980). Wealth of a Nation To Be: The American Colonies on the Eve of the Revolution. New York: Columbia Univ. Press. Jones, D.L. (1981). Village and Seaport: Migration and Society in Eighteenth-Century Massachusetts. Hanover, N.H.: New England Press. Jones, E.F., J.D. Forrest, N. Goldman, S. Henshaw, R. Lincoln, J.I. Rosoff, C.F. Westoff, and D. Wulf (1986). Teenage Pregnancy in Industrialized Countries. New Haven, Conn.: Yale Univ. Press. Jones, E.F., L. Paul, and C.F. Westoff (1980). "Contraceptive Efficacy: The Significance of Method and Motivation." Studies in Family Planning II, pp. 39–50. JRB Associates (1981). Final Report on National Study of Teenage Pregnancy. DHHS Contract No. 282-80-0070-LG. Juster, S.M., and M.A. Vinovskis (forthcoming). "Changing Perspectives on the American Family in the Past." In Annual Review of Sociology 13. Kaestle, C.F., and M.A. Vinovskis (1980). Education and Social Change in

References

261

Nineteenth-Century Massachusetts. Cambridge: Cambridge Univ. Press. —— (1978). "From Apron Strings to ABCs: Parents, Children, and Schooling in Nineteenth-Century Massachusetts." In Turning Points: Historical and Sociological Essays on the Family, eds. J. Demos and S. Boocock. Chicago: Univ. of Chicago Press, pp. S539-S580. Kahn, J.S., and F.G. Boltori, Jr. (1986). "Clinical Issues in Adolescent Fatherhood." In Adolescent Fatherhood, eds. A.B. Elster and M.E. Lamb. Hillsdale, N.J.: Lawrence Erlbaum, pp. 141-154. Katz, M.B. (1986). In the Shadow of the Poorhouse: A Social History of Welfare in America. New York: Basic Books. Kennedy, D.M. (1970). Birth Control in America: The Career of Margaret Sanger. New Haven, Conn.: Yale Univ. Press. Kenny, A.M., Forrest, J.D., and A. Torres (1982). "Storm over Washington: The Parental Notification Proposal." Family Planning Perspectives 14, pp. 185-196. Kerber, L. (1980). Women of the Republic: Intellect and Ideology in Revolutionary America. Chapel Hill, N.C. Univ. of North Carolina Press. Kelt, J.F. (1977). Rites of Passage: Adolescence in America, 1790 to the Present. New York: Basic Books. Klerman, L.V. (1981). "Programs for Pregnant Adolescents and Young Parents: Their Development and Assessment." In Teenage Parents and Their Offspring, eds. K.G. Scott, T. Field, and E. Robertson. New York: Grune and Stratton, pp. 227-248. —— (1979). "Evaluating Service Programs for School-Age Parents: Design Problems." Evaluation and the Health Professions 1, pp. 5570. Klerman, L.V., and J.F. Jekel (1973). School-Age Mothers: Problems, Programs, and Policy. Hamden, Conn.: Linnet. Klinman, D.G., J. H. Sander, J.L. Rosen, and K.R. Longo (1986). "The Teen Father Collaboration: A Demonstration and Research Model." In Adolescent Fatherhood, eds. A.B. Elster and M.E. Lamb. Hillsdale, N.J.: Lawrence Erlbaum, pp. 155-170. Kuhn, A.L. (1947). The Mother's Role in Childhood Education. New Haven, Conn.: Yale Univ. Press. Lader, L. (1955). The Margaret Sanger Story. Garden City, N.Y.: Doubleday. Lamb, M.E., ed. (1981). The Role of the Father in Child Development. 2nd ed. New York: John Wiley.

262

References

Lamb, M.E., and A. Sagi, eds. (1983). Fatherhood and Family Policy. Hillsdale, N.J.: Lawrence Erlbaum. Laslett, P. (1971). "Age at Menarche in Europe Since the Eighteenth Century." Journal of Interdisciplinary History 2, pp. 221-236. Laslett, P., K. Oosterveen, and R.M. Smith, eds. (1980). Bastardy and its Comparative History. Cambridge, Mass.: Harvard Univ. Press. Leridon, H. (1977). Human Fertility: The Basic Components. Trans. J. F. Helzner. Chicago: Univ. of Chicago Press. Levy, S.B., and W.J. Grinker (1983). Choices and Life Circumstances: An Ethnographic Study of Project Redirection Teens. New York: Manpower Demonstration Research Corporation. Lewis, J. (1983). The Pursuit of Happiness: Family and Values in Jefferson's Virginia. Cambridge: Cambridge Univ. Press. Littlewood, T.B. (1977). The Politics of Population Control. South Bend, Ind.: Univ. of Notre Dame Press. Lockridge, K.A. (1974). Literacy in Colonial New England: An Enquiry into the Social Context of Literacy in the Early Modern West. New York: Norton. —— (1970). A New England Town, the First Hundred Years: Dedham, Massachusetts. New York: Norton. Los Angeles Times. McCarthy, J., and J. Menken (1978). "Marital Consequences of Age at First Birth." Paper presented at the Workshop on Consequences of Adolescent Pregnancy and Childbearing. Center for Population Research. NICHHD, Bethesda, Maryland McCathren, R.R. (1981). "The Demise of Federal Categorical Child Care Legislation: Lessons for the '80s from the Failures of the '70s." In Approaches to Child and Family Policy. H.C. Wallach, ed. Boulder, Colo.: WestviewPress, pp. 101–143. McLauhlin, S.D. (1977). Final Report to Center for Population Research. NICHHD. No. NO1-HD-62832. McLaughlin, S.D., Grady, W.R., Billy, J.O.G., Landale, N.S., and L.D. Winges (1986). "The Effects of Sequencing of Marriage and First Birth During Adolescence." Family Planning Perspectives 18, pp. 12-18. McLoughlin, W.G. (1978). Revivals, Awakenings, and Reform. Chicago: Univ. of Chicago Press. Malmsheimer, L.M. (1973). "New England Funeral Sermons and Changing Attitudes Towards Women, 1672–1792." Unpublished Ph.D. thesis, Univ. of Minnesota. Mason, K., M.A. Vinovskis, and T.K. Hareven (1978). "Women's Work

References

263

and the Life Course in Essex County, Massachusetts, 1880." In Transitions: The Family and the Life Course in Historical Perspective. New York: Academic Press, pp. 187-216. Mason, W.M., and S.E. Fienberg, eds. (1985). Cohort Analysis in Social Research: Beyond the Identification Problem. New York: SpringerVerlag. Massachusetts. Census of Massachusetts, 1885 (1887) 4 vols. Boston: Wright and Potter. May, E.T. (1980). Great Expectations: Marriage and Divorce in PostVictorian America. Chicago: Univ. of Chicago Press. May, D., and M.A. Vinovskis. (1976). "A Ray of Millenial Light: Early Education and Social Reform in the Infant School Movement in Massachusetts, 1826-1840." In Family and Kin in American Urban Communities, 1800–1940. T.K. Hareven, ed. New York: Watts, pp. 62-99. Mecklenburg, M. (1981a). Memorandum to the Assistant Secretary for Health Containing Comments on October 2 Draft NPRM—Title X Regulations. Oct. 5. —— (1981b). Memorandum to Juan A. del Real on Reactions to Your October 19th Draft of Revision of Family Planning Regulations. Oct. 23. Miller, W.B. (1976). "Sexual and Contraceptive Behavior in Young Unmarried Women." Primary Care 3, pp. 427-453. Mnookin, R.H. (1985). "Bellotti v. Baird: A Hard Case." In In the Interest of Children: Advocacy, Law Reform, and Public Policy, ed. R.H. Mnookin. New York: Freeman. Mohr, J.C. (1978). Abortion in America: The Origins and Evolution of National Policy. New York: Oxford Univ. Press. Moore, K.A. (1978). "Teenage Childbirth and Welfare Dependency." Family Planning Perspectives 10, pp. 233-235. Moore, K.A., and M.R. Burt. (1982). Private Crisis, Public Cost: Policy Perspectives on Teenage Childbearing. Washington, D.C.: Urban Institute Press. Moore, K.A., and S.B. Caldwell (1977). "Early Childbearing and Educational Attainment." Family Planning Perspectives 9, pp. 220-225. —— (1976). Out-of-Wedlock Pregnancy and Childbearing. Working Paper No. 992-02. Urban Institute. Moore, K.A., and L.J. Waite (1977). "Early Childbearing and Educational Attainment." Family Planning Perspectives 9, pp. 220-225. Moore, K.A., Wenk, D.A.L., Hofferth, S.L., and C.D. Hayes (forthcoming). "Statistical Appendix: Trends in Adolescent Sexual and Fertil-

264

References

ity Behavior." In Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing, eds. C.D. Hayes, and S.L. Hofferth. Vol. II. Washington, D.C.: National Academy Press. Moran, G.F. (1980). "Sisters in Christ: Women and the Church in Seventeenth-Century New England." In Women in American Religion. J.W. James, ed. Philadelphia: Univ. of Pennsylvania Press pp. 47-65. Moran, G.F., and MA. Vinovskis (1986). "The Great Care of Godly Parents: Early Childhood in Puritan New England." In History and Research in Child Development, eds. A.B. Smuts, and J.W. Hagen. Monographs of the Society for Research in Child Development 50, 24-37. —— (1982). "The Puritan Family and Religion: A Critical Reappraisal." William and Mary Quarterly 3rd Series 39, pp. 29-63. Morgan, E.S. (1966). The Puritan Family: Religion and Domestic Relations in Seventeenth-Century New England. New York: Harper and Row. Mosteller, F., and D.P. Moynihan, eds. (1972). On Equality of Educational Opportunity. New York: Vintage. Murray, C. (1984). Losing Ground: American Social Policy, 1950-1980. New York: Basic Books. National Conference of Catholic Charities (1982). Comments on the Proposed DHHS Regulations. April 22. —— (1981). Draft of Proposed Revision of Title VI—Grant Program. National Family Planning and Reproductive Health Association (NFPHRA) (1982). Comments on the Proposed DHHS Regulations. April 23. —— Forum. New York Times. Norton, D. (1974). "Parental Age as a Factor in Pregnancy Outcomes and Child Development." Reports on Population/Family Planning No. 16. Norton, M.B. (1984). "The Evolution of White Women's Experience in Early America." American Historical Review 89, pp. 593-619. —— (1980). Liberty's Daughters: The Revolutionary Experience of American Women, 1750-1800. Boston: Little Brown. Norton, S.L. (1981). "Age at Marriage and Marital Migration in Three Massachusetts Towns, 1660-1850." Unpublished Ph.D. thesis, University of Michigan. "Office of Adolescent Pregnancy Programs, Department of Health and Human Services." (1980) Information Bulletin. Ory, H.W., Forrest, J.D., and R. Lincoln (1983). Making Choices: Evalu-

References

265

ating the Health Risks and Benefits of Birth Control Methods. New York: Alan Guttmacher Institute. Parkes, H.B. (1932) "Morals and Law Enforcement in Colonial New England." New England Quarterly 5, pp. 431-435. Paul, E.W., H.F. Pilpel, and N.F. Wechsler (1974). "Pregnancy, Teenagers and the Law, 1974." Family Planning Perspectives 6, pp. 142– 147. Perlman, J. (1982). "Update on the Health Consequences of Prescription Methods of Birth Control by Adolescents." Memo to Acting Deputy Assistant Secretary for Population Affairs. NIH, Ja. 12. Physiology of Marriage. (1856). Boston: John P. Jewett. Pilpel, H.F., and N.F. Wechsler (1971). "Birth Control, Teen-Agers and the Law: A New Look, 1971." Family Planning Perspectives pp. 37-45. Piotrow, P.T. (1973). World Population Crisis: The United States Response. New York: Praeger. Piven, F.F., and R.A. Cloward. (1971). Regulating the Poor: The Functions of Public Welfare. New York: Random House. Planned Parenthood of Central Missouri v. Danforth (1976). 428 U.S. 52. Planned Parenthood Federation of America v. Heckler (1983). 229 U.S. App. D.C. 336. Planned Parenthood Federation of America v. Schweiker (1983). 559 F. Supp. 658. Planned Parenthood Federation of America (PPFA) (1982). Comments on the Proposed DHHS Regulations. April 12. Polgar, S., and E. Fried. (1976). "The Bad Old Days: Clandestine Abortions Among the Poor in New York City Before Liberalization of the Abortion Law." Family Planning Perspectives 8, pp. 125127. Polit, D.F., M.B. Tannen, and J.R. Kahn(1983). School, Work and Family Planning: Interim Impacts in Project Redirection. New York: Manpower Demonstration Research Corporation. Pomeroy, R., and L.C. Landman (1972). "Public Opinion Trends: Elective Abortion and Birth Control Services to Teenagers." Family Planning Perspectives 4, pp. 44–55. Potter, J. (1984). "Demographic Development and Family Structure." In Colonial British America: Essays in the New History of the Early Modern Era. J.P. Greene and J.R. Pole, eds. Baltimore: Johns Hopkins Press, pp. 123–156. Pratt, W.F., Mosher, W.D., Bachrach, C.A., and M.C. Horn (1984). "Understanding U.S. Fertility: Findings from the National Survey of Family Growth, Cycle III." Population Bulletin 39, pp. 1-42.

266

References

Rainwater, L., and W.L. Yancey (1967). The Moynihan Report and the Politics of Controversy. Cambridge: Mass.: MIT Press. Reed, J. (1985). "Public Policy on Human Reproduction and the Historian. "Journal of Social History 18, pp. 383-398. —— (1983). The Birth Control Movement and American Society: From Private Vice to Public Virtue. Rev. ed. Princeton, N.J.: Princeton Univ. Press. Rosoff, J.I. (1981). "Blocking Family Planning," Family Planning Perspectives 13, pp. 125–131. —— (1978). "Sex, Teenagers and the Government. Planned Parenthood-World Population." Washington Memo 1–4. Rothman, D.J. (1971). The Discovery of the Asylum: Social Order and Disorder in the New Republic. Boston: Little Brown. Rothman, E.K. (1984). Hands and Hearts: A History of Courtship in America. New York: Basic Books. Rutman, D.B., and A.M. Rutman (1984). A Place in Time: Middlesex County, Virginia, 1650–1750. New York: Norton. Ryan, M.P. (1981). Cradle of the Middle Class: The Family in Oneida County, New York, 1790-1865. New York: Cambridge Univ. Press. Schirm, A.L., J. Trussell, J. Menken, and W.R. Grady (1982). "Contraceptive Failure in the United States: The Impact of Social, Economic and Demographic Factors." Family Planning Perspectives 14, pp. 68-75. Schlossman, S., and S. Wallach. (1980). "The Crime of Precocious Sexuality: Female Juvenile Delinquency in the Progressive Era." Harvard Educational Review 48, pp. 65-94. Sedlack, M.W. (1980). "The Education of 'Girls with Special Needs,' 1865-1972." Unpublished paper presented at Teacher's College Conference on History of Urban Education. Shorter, E. (1975). The Making of the Modern Family. New York: Basic Books. Shriver, E.K. (1977). Letter to Jospeh A. Califano, Secretary, Department of Health, Education, and Welfare. Oct. 21. Smith, D.B. (1980). Inside the Great House: Planter Family Life in Eighteenth-Century Chesapeake Society. Ithaca, N.Y.: Cornell Univ. Press. Smith, D.S. (1973). "Parental Power and Marriage Patterns: An Analysis of Historical Trends in Hingham, Massachusetts." Journal of Marriage and the Family 35, pp. 406-418. —— (1972). "The Demographic History of New England." Journal of Economic History 32 pp. 165-183.

References

267

Smith, D.S., and M.S. Hindus. (1975). "Premarital Pregnancy in America, 1640-1971: An Overview and Interpretation." Journal of Interdisciplinary History 5, pp. 537–570. Smith-Rosenberg, C. (1971). "Beauty, the Beast, and the Militant Woman: A Case Study in Sex Roles and Social Stress in Jacksonian America. "American Quarterly 23, pp. 562-584. Soltow, L., and E. Stevens (1981). The Rise of Literacy and the Common School in the United States: A Socioeconomic Analysis to 1870. Chicago: Univ. of Chicago Press. Stannard, D.E. (1975). "Death and the Puritan Child." In Death in America, ed. D.E. Stannard. Philadelphia: Univ. of Pennsylvania Press, pp. 9–29. State of N. Y. v. Heckler (1983). 719 F.2d. Steiner, G.Y. (1976). The Children's Cause. Washington, D.C. Brookings Institution. —— (1971). The State of Welfare. Washington, D.C.: Brookings Institution. Steinfels, M.O. (1973). Who's Minding the Children? The History and Politics of Day Care in America. New York: Simon and Schuster. Stiles, H.R. (1934). Bundling: Its Origin, Progress, and Decline in America. New York: Book Collectors Association. Stine, O.C. (1964). "School Leaving Due to Pregnancy in an Urban Adolescent Population." American Journal of Public Health 54, pp. 16. Stone, L. (1977). The Family, Sex, and Marriage in England, 1500-1800. New York: Harper and Row. Sweet, L.I. (1983). The Minister's Wife: Her Role in Nineteenth-Century American Evangelicalism. Philadelphia: Temple Univ. Press. T.H. v. Jones (1976). 425 F. Supp. 873. Talwar, P.P. (1965). "Adolescent Sterility in an Indian Population." Human Biology 37, pp. 256-261. Tanner, J.M. (1965). "The Trend Toward Earlier Physical Maturation." In Biological Aspects of Social Problems, eds. A.S. Parker and J.D. Mead. New York: Plenum Press, pp. 40-65. Tate, T.W., and D.L. Ammerman, eds. (1979). The Chesapeake in the Seventeenth Century: Essays on Anglo-American Society and Politics. New York: Norton. Thernstrom, S. (1964). Poverty and Progress: Social Mobility in a Nineteenth-Century City. Cambridge, Mass.: Harvard Univ. Press. Thompson, R. (1986). Sex in Middlesex: Popular Mores in a Massachusetts County, 1649-1699. Amherst, Mass.: Univ. of Massachusetts Press.

268

References

(1984). "Adolescent Culture in Colonial Massachusetts." Journal of Family History 9, pp. 127-144. Tieze, C. (1978). "Teenage Pregnancies: Looking Ahead to 1984." Family Planning Perspectives 10, pp. 205-207. Tilly. L.A., and S.W. Scott (1978). Women, Work, and Family. New York: Holt, Rinehart, and Winston. Torres, A. (1978). "Does Your Mother Know . . . ?" Family Planning Perspectives 10, pp. 280-282. —— (1976). "Teenage Income and Clinic Fees. "Family Planning Perspectives 8, pp. 263-266. Torres, A., and S. Eisman (1980). "The Impact of Restrictions on the Provision of Birth Control and Abortion Services on Teenage Fertility." Paper presented at the APHA Meeting. Torres, A., and J.D. Forrest (1985). "Family Planning Clinic Services in the United States." Family Planning Perspectives 17, pp. 30-35. —— (1983). "Family Planning Clinic Services in the United States, 1981." Family Planning Perspectives 15, pp. 272-278. Torres, A., J.D. Forrest, and S. Eisman (1981). "Family Planning Services in the United States, 1978-1979." Family Planning Perspectives 13, pp. 132–141. —— (1980). "Telling Parents: Clinic Policies and Adolescents' Use of Family Planning and Abortion Services." Family Planning Perspectives 12, pp. 284-292. Tracy, P.J. (1979). Jonathan Edwards, Pastor: Religion and Society in Eighteenth-Century Northampton. New York: Hill and Wang. Trattner, W.I. (1984). From Poor Law to Welfare State: A History of Social Welfare in America. 3rd Ed. New York: Free Press. Traugott, M.W., and M.A. Vinovskis (1980). "Abortion and the 1978 Congressional Elections." Family Planning Perspectives 12, pp. 238-246. Trussell, J., and R. Steckel (1978). "The Age of Slaves at Menarche and their First Birth." Journal of Interdisciplinary History 8, pp. 477505. Trussell, J., and C.F. Westoff (1980). "Contraceptive Practice and Trends in Coital Frequency." Family Planning Perspectives 12, pp. 246249. Tuma, N.B., and M.T. Hannan, eds. (1984). Social Dynamics: Models and Methods. New York: Academic Press. Ulrich, L.T. (1982). Good Wives: Image and Reality in the Lives of Women in Northern New England, 1650-1750. New York: Alfred Knopf. Urban and Rural Systems Associates (1976). Improving Family Planning ——

References

269

Services for Teenagers. Final Report Submitted to Office of Assistant Secretary of Planning and Evaluation/Health, DHEW. Contract HEW-OS-74-304. U.S., Bureau of Census (1971). People of the United States in the 20th Century. Washington, D.C.: Government Printing Office. U.S., Congress. Congressional Record. U.S., Congress. House. Committee on Education and Labor (1978). Hearings, Adolescent Health, Services, and Pregnancy Care Act of 1978. 95th Cong., 2d Sess.. U.S., Congress. House. Committee on Energy and Commerce (1984). Hearings, Adolescent Family Life Act Reauthorization. 98th Cong., 2d Sess. U.S., Congress. House. Committee on Energy and Commerce (1982). Hearings, Health and the Environment, Miscellaneous—Part 7. 97th Cong., 2d Sess. U.S., Congress. House. Committee on Interstate and Foreign Commerce (1978). Hearings, Adolescent Health, Services, and Pregnancy Prevention and Care Act of 1978. 95th Cong., 2d Sess. U.S., Congress. House. Committee on Interstate and Foreign Commerce (1970). Hearings, Family Planning Services. 91st Cong., 2d Sess. U.S., Congress. House. Report 97–208 (1981). U.S., Congress. House. Select Committee on Population (1978a). Hearings, Fertility and Contraception in America. II. 95th Cong., 2d Sess. U.S., Congress. House. Select Committee on Population (1978b). Fertility and Contraception in the United States. 95th Cong., 2d Sess., Serial B. U.S., Congress. Senate. Committee on Government Operations (1967). Hearings, Population Crisis. Parti. 90th Cong., 1st Sess. U.S., Congress. Senate. Committee on Human Resources (1978a). Hearings, Adolescent Health, Services, and Pregnancy Prevention and Care Act of 1978. 95th Cong., 2d Sess. U.S., Congress. Senate. Committee on Human Resources (1978b). Report on the Adolescent Health, Services, and Pregnancy Prevention and Care Act of 1978. 95th Cong., 2nd Sess. U.S., Congress. Senate. Committee on Labor and Human Resources (1981a). Hearings, Oversight on Family Planning Programs under Title X of the Public Health Service Act of 1981. 97th Cong., 1st Sess. U.S., Congress. Senate. Committee on Labor and Human Resources (1981b). Report on Adolescent Family Life Act of 1981. 97th Cong., 1st Sess. U.S., Congress. Senate. Committee on Labor and Human Resources

270

References

(1981c). Hearings, Health Services and Preventive Health Block Grants, 1981. 97th Cong., 1st Sess. U.S., Congress. Senate. Committee on Labor and Public Welfare (1975). Hearings, School-Age Mother and Child Health Act of 1975. 94th Cong., 1st Sess. U.S., Congress. Senate. Committee on Labor and Public Welfare (1973). Hearings, Family Planning Services and Population Research Amendments of 1973. 93rd Cong., 1st Sess. U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs (1981a). Transition Briefing Material. U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs (1981). Information Bulletin. U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs (1980). Information Bulletin. U.S., Department of Health and Human Services, Office of Adolescent Pregnancy Programs (1980b). Memorandum from the Director of OAPP to Lyndia Greene, Contracting Specialist. Aug. 27. U.S., Department of Health, Education, and Welfare. HEW News. U.S., Department of Health, Education, and Welfare, Office of Child Health Affairs (1976). Teenage Pregnancy. U.S., Department of Health, Education, and Welfare, Office of Planning and Evaluation (1977). Initiative to Address Adolescent Pregnancy and Related Issues—Decision Memorandum. Aug. 4. U.S., Department of Health, Education, and Welfare, Special Task Force (1977). Family Development Program. March 17. U.S., Department of Health, Education, and Welfare, Task Force on Alternatives to Abortion (1977). Report from the Chair of the Task Force on Alternatives to Abortions. July 25. U.S., Federal Register. Valentine, J. and E.F. Zigler (1983). "Head Start: A Case Study in the Development of Social Policy for Children and Families." In Children, Families and Government: Perspectives on American Social Policy, eds. E.F. Zigler, S.L. Kagan, and E. Klugman. Cambridge: Cambridge Univ. Press, pp. 266–280. Vinovskis, M.A. (forthcoming). "Life Course Analysis and the Historian: Reflections on Applications of the Life Course to the Study of American Family Life in the Past." In Life-Span Developmment and Behavior, eds. P.B. Baltes, D.L. Featherman, and R.M. Lerner. Hillsdale, N.J.: Erlbaum. —— (1983). "American Families in the Past." In Ordinary People and Everyday Life: Perspectives on the New Social History. J.B. Gard-

References

271

ner, and G.R. Adams, eds. Nashville, Tenn.: American Association for State and Local History, pp. 115–137. —— (1981a). "An 'Epidemic' of Adolescent Pregnancy? Some Historical Considerations." Journal of Family History 6, pp. 205-230. —— (1981b). Fertility in Massachusetts from the Revolution to the Civil War. New York: Academic Press. —— (1980a). "Abortion and the Presidential Election of 1976: A Multivariate Analysis of Voting Behavior." In The Law and Politics of Abortion. C.E. Schneider, and M. A. Vinovskis, eds. Lexington, Mass.: Lexington Books, pp. 184-205. —— (1980b). "The Politics of Abortion in the U.S. House of Representatives in 1976." In The Law and Politics of Abortion, eds. C.E. Schneider, and M.A. Vinovskis. Lexington, Mass.: D.C. Heath, pp. 224-261. —— (1978). "Recent Trends in American Historical Demography: some Methodological and Conceptual Considerations." Annual Reviews of Sociology 4, pp. 603–627. —— (1977). "From Household Size to the Life Course: Some Observations on Recent Trends in Family History." American Behavioral Scientist 21, pp. 263-287. —— (1970). "Horace Mann on the Economic Productivity of Education." New England Quarterly 43, pp. 550-571. Vinovskis, M.A., R.M. Jones, and T. New (1974). "Determinants of Legislative Voting Behavior on Population Policy: An Analysis of the Massachusetts House of Representatives in 1970 and 1971. In Population Policymaking in the American States, eds. E. Bergman et al. Lexington, Mass.: D.C. Heath, pp. 239-255. Wall Street Journal. Walsh, L.S. (1979). " 'Till Death Us Do Part': Marriage and Family in Seventeenth-Century Maryland." In The Chesapeake in the Seventeenth Century: Essays on Anglo-American Society and Politics, eds. T.W. Tate, and D.L. Ammerman. New York: Norton, pp. 126-152. Walsh, M.R. (1977). Doctors Wanted, No Women Need Apply: Sexual Barriers in the Medical Profession, 1835-1975. New Haven, Conn.: Yale Univ. Press. Walton, G.M., and J.F. Shepherd (1979). The Economic Rise of Early America. Cambridge: Cambridge Univ. Press. Warner, S.B., Jr. (1963). Streetcar Suburbs. Cambridge, Mass.: Harvard Univ. Press. Washington Memo.

272

References

Wallenberg, B.J. (1978). 1978: The U.S. Fact Book. New York: Grossel and Dunlap. Weeks, J.R. (1976). Teenage Marriages: A Demographic Analysis. Westpoint, Conn.: Greenwood Press. Weilzman, L.J., and R.B. Dixon. (1979). "Child Custody Awards: Legal Slandards and Empirical Patterns for Child Custody, Supporl and Visilalion After Divorce." University of California Davis Law Review 12, pp. 472-521. Wells, R.V. (1980). "Illegilimacy and Bridal Pregnancy in Colonial America." In Bastardy and Its Comparative History. P. Laslelt, K. Ooslerveen, and R.M. Smith, eds. Cambridge, Mass.: Harvard Univ. Press, pp. 349–361. —— (1975). The Population of the British Colonies in America before 1776: A Survey of Census Data. Princeton: Princeton Univ. Press. Welter, B. (1966). "The Cult of True Womanhood, 1820-1860." American Quarterly 18, pp. 151-174. Westinghouse Learning Corp. (1969). The Impact of Head Start: An Evaluation of the Effects of Head Start on Children's Cognitive and Affective Development. Ohio University Report to the Office of Economic Opportunity. Washington, D.C.: Clearinghouse for Federal Scientific and Technical Information, ED036321. Westoff, C.F., and N.B. Ryder (1977). The Contraceptive Revolution. Princeton: Princeton Univ. Press. Williams, P.R. (1977). Black Illegitimacy and Social Response. Research Report for Center for Population Research. NICHHD. No. NOHD-52825. Wilmington News Journal. Winston, D.A. (1981). "Health and Human Services." In Mandate for Leadership: Policy Management in a Conservative Administration, ed. C.L. Heatherly. Washington, D.C.: Heritage Foundation, pp. 245-306. Wyshak, G., and R.E. Frisch (1982). "Evidence for a Secular Trend in Age of Menarche." New England Journal of Medicine 306, pp. 1033–1035. Yans-McLaughlin, V. (1977). Family and Community: Italian Immigrants in Buffalo, 1880-1930. Ithaca, N.Y.: Cornell Univ. Press. Zabin, L.S., J.F. Kantner, and M. Zelnik (1979). "The Risk of Adolescent Pregnancy in the First Months of Intercourse." Family Planning Perspectives 11, pp. 215–222. Zelnik, M., and J.F. Kantner (1980). "Sexual Activity, Contraceptive Use and Pregnancy Among Metropolian-Area Teenagers, 1971-1979." Family Planning Perspectives 12, pp. 230-237.

References ——

273

(1978a). "Contraceptive Patterns and Premarital Pregnancy Among Women Aged 15 to 19 in 1976." Family Planning Perspectives 10, pp. 135–142. —— (1978b). "First Pregnancies in Women Aged 15 to 19: 1976 and 1971." Family Planning Perspectives 10, pp. 11-20. —— (1977). "Sexual and Contraceptive Experience of Young Unmarried Women in the United States, 1976 and 1971." Family Planning Perspectives 9, pp. 55–71. Zelnik, M., J.F. Kantner, and K. Ford (1981). Sex and Pregnancy in Adolescence. Beverly Hills, Calif.: Sage Publications. Zigler, E., and J. Valentine, eds. (1979). Project Head Start: A Legacy of the War on Poverty. New York: Free Press. Zimring, F.E. (1982). The Changing Legal World of Adolescence. New York: Free Press. Zinaldin, J.S. (1979). "The Emergence of a Modern American Family Law: Child Custody, Adoption, and the Courts, 1796-1851." Northwestern University Law Review 73, pp. 1038-1089.

Index

Abert, J. G., 180 Abortion, access to services, 91–92, 132–33; alternatives to, 39–40, 53– 55, 168; counseling, 52, 66–67, 80, 82-83; determinants, 167; in early America, 10, 16, 88; facilities for performing, 132-33; legalization of, 164, 221n; numbers and rates of, 164, 211, 213, 221n; and parental notification requirement, 118; politics of, 39–40, 54–55, 66, 82– 83, 102, 127–28, 171–72; race differences in, 132–33; research on, 226n Abstinence, see Initiation of sexual activity Acquired immune deficiency virus (AIDS), 213 Adelson, E., 42–43 Adolescent development, factor in sexual activity, 42–43; and parental notification controversy, 104, 1079, 121; as stage of life in early America, 16–18, 21, 159, 161–63 Adolescent Family Life Act, Title XX, 42, 85-86, 99, 123, 129-30, 173-78, 197–200, 204–5, 208–9, 217, 231n, 238n, 249n-52n Adolescent Family Life Program, 48, 79, 84, 99, 129, 173, 179, 198, 204, 217. See also Adolescent Family Life Act, Title XX; Office of Adolescent Pregnancy Programs Adolescent Health Services and Pregnancy Prevent and Care Act of 1978, 22-40, 47, 50, 57-58, 60, 64, 67-70, 86, 94, 168-173, 219n-20n, 224n-25n, 228n, 230n. See also Health Services and Centers Amendments Act, Title VI–VIII; Office of Adolescent Pregnancy Programs

Adolescent Pregnancy Initiative, 36– 37, 56, 61 Adolescent Pregnancy Related Issues Task Force, 35 Adoption, 29–31, 48, 52, 80, 82, 86, 176, 222n Agency for International Development (AID), 89 Ager, J. W., 117, 152 Agronow, J., 117, 152 Aid to Families with Dependent Children, 30, 41, 92 Alabama, 78 Alan Guttmacher Institute (AGI), xiv, xviii, 40, 82,113,123,125,128,13132,137-39,143,146,154-55,188, 221n, 227n, 235n, 239n-42n, 248n Alternative life styles, 43 Alternative National Curriculum, 176 Alternatives to Abortion Program, 54, 168 American Academy of Pediatrics, 115 American Bar Association, 115 American Citizens Concerned for Life, 63, 115, 227n American Civil Liberties Union, 115, 122 American College of Obstetricians (ACOG), 90 American Life Lobby, 115, 127 American Medical Association, 115 American Public Health Association, 115 American Revolution, 160 Anderson, C. A., 100-102, 112-13, 233n Andover, Mass., 10, 13 Apter, D., 149-50 Aries, P., 17 Auwers, L., 159 Axtell, J., 158

274

Index Bachrach, C. A., 35 Baldwin, W. H., 170, 222n Baltes, P. B., 228n Baltimore, Md., 49, 54–55, 57–58, 63, 82-83, 117, 182-88, 190, 195, 202, 205-7, 232n,244n-47n Baltimore study, 49, 182-88, 195, 202, 205-7, 244n-46n, 250n Bancroft, D. R. E., 51, 184 Baron, T.,233n Battelle Memorial Institute, 178, 243n Bayh, B., 50–51, 53–55 Beales, R., 18 Bedford-Stuyvesant, New York, 201 Beilenson, A., xiv, 224n Berg, B. J., 16 Berlin Wall, 236n Bible, 159 Billy, J. O. G.,31,243n Birth control pills, see Contraceptive pills Births to adolescents, negative effects on mother, 18, 24-26, 39, 49, 59; numbers and rates of, 24-28, 44, 48, 163, 211, 227n; in Western Europe, 213. See also Nonmarital childbearing Bolton,F. G., 243n Boston, Mass., 20, 44, 57, 201–2, 219n Bowditch, N.,5–6 Braedmas, J., 58 Brandt, E. 3N., 100, 102–3, 110, 233n–34n, 238n Brenzel, B.,16, 163 Brookings Institution, 227n Brooks-Gunn, J., 184–87, 195, 205– 8, 228n, 244n–46n, 250n Brown, J., 127 Brumberg, J. J., 163, 219n Brundtland, G. H.,4 Bullough, V., 15, 18 Bundling, 14 Bureau of Community Health Services, 100, 238n Bureau of Health Care Delivery and Assistance, 237n Burt, M. R., 164, 174, 191, 194, 19697, 200-201, 205, 207-9, 221n, 249n-50n

275 Caldwell, S. B.,7, 18,41 Calhoun, A., 7–8 Califano, J. A., xii, 54–56, 58, 61, 70, 168, 172, 230n California, 32, 176, 223n Campbell, A. A., 185, 222n Canada, 213 Card, J. J . , 7 , 18, 221n Carey v. Population Services International, 91 Carter Administration, xii, xiv-xv, xvii, xix, 22-25, 28, 30-32, 36-37, 39–42, 47–48, 53–54, 56–60,62– 65, 68–71, 76–77, 80, 85, 92, 168, 173, 179, 219n–20n, 223n–25n, 229n, 246n–47n Carter, J., 54, 56, 70, 76, 230n Cath, S. H.,158 Catholics, 79, 88 CBS News, 120, 237n Center for Family Planning Program Development, 89 Center for Population Research, 41, 60, 66, 86, 170, 207, 247n Centers for Disease Control, 242n CETA, 191 Chambers, D. L., 179 Chamie, M., 141, 241n Charles County Teenage Parenting Program, 190 Chase-Lansdale, L., 179, 243n Chicago Tribune, 118–19 Child and Family Services Act of 1975, 50–51 Child Health and Assurance Act of 1979, 95 Child support, enforcement, 158, 160-61, 179; father's liability for, 32, 163, 166-68, 171-73, 177, 216 Childbearing by adolescents, see Births to adolescents; Legitimation, Nonmarital childbearing; Pregnancy Children's Bureau, 49, 52, 180-83, 188, 200, 204-5, 208, 229n, 244n Children's Defense Fund, 115 Chilman,C. S., 43–44, 224n Clarke, E. H.,6, 163 Clinics, see Family planning clinics; School-based clinics Cloward, R. A.,243n

276 Coalition for School-Age Mothers, 186, 188 Columbia University, 182, 208 Commission on Population Growth and the American Future, 90-91 Commonwealth Fund, 244n Community Maternity Services, 190 Comprehensive care programs, core services, 51, 58, 62-65, 72, 79, 8385, 186, 189–90, 193, 205, 245n; costs, 194, 203, 207–8, 248n–49n; duration of effects, 51, 185–86, 206, 245n; establishment of, 47–86; and increase in pregnancies, 64; integration of services, 50–52, 55, 57-60, 65-66, 72, 74; outcome evaluations of, 52, 58, 60-61, 68-69, 71-76, 85-86, 180-210, 217, 229n; prevalence of, 49-50; repeat pregnancies, 49-50, 73, 134, 215-16 Comstock, A., 88 Condoms, attitudes about, 134, 21516; effectiveness, 145; and prevention of sexually transmitted diseases, 215-16; rates of use, 140-41 Congressional Record, 67-68, 80-81, 94–95, 250n Connecticut, 89, 183, 244n Consortium on Early Childbearing and Childrearing, 49, 229n Conte,S., 129,238n Contraceptive pills, effectiveness, 38, 143; health complications of, 106, 152-53, 215, 235n-36n; perceptions of health risks, 215, 225n; prevalence of use, 35, 134; research needs on, 215, 225n Contraceptive services, access to, 27, 36, 183; attitudes about, 38, 88-89, 124, 213-14; availability of, 38, 48-49; costs of providing, 53-54, 56, 141, 233n–34n, 239n, 241n; effectiveness, 62, 142-45; legalization of, 87-94, 126; parental notification requirement impact on, 131–56, 239n–42n. See also Family planning clinics; Family Planning Services and Population Research Act, Title X; Schoolbased clinics Contraceptive use, in early America,

INDEX 16, 87-88; gender roles and, 169, 172, 174, 215-16; rates among teenagers, 35; regularity of use, 35. See also specific contraceptives Cost-benefit analysis, 43, 184-85 Costs, adolescent pregnancy and parenting, 24–25, 30–32, 38–39, 59, 94, 226n; comprehensive care programs, 51, 53-54, 194; contraception, 53-54, 56, 141, 239n; Project Redirection, 203; sex and family life education programs, 53-54 Cott, N. F., 162 Courts and parental notification, 8992, 100, 120–24, 126 Currie, J. B., 51, 184 Cutright, P., 163 Cyesis Program Consortium, 49 Dannemeyer, W. F,, 95, 233n Data Archive on Adolescent Pregnancy, 190, 194, 207, 249n David, P. A., 5 Degler, C. N . , 9 , 162 Del Real, J. A., 101–4, 108–10, 234n Delaware Adolescent Program, Inc. (DAPI), 50, 51, 57, 63, 70, 190, 247n Delay of sexual initiation, see Initiation of sexual activity Democrats, 76, 81, 217, 237n Demos, J., 8, 17-18, 159, 162-63, 242n Demos, V., 17-18, 159, 163 Dennett, M. W.,88 Denton, J., xvii, 9, 77–86, 96-99, 102, 114-15, 129, 175, 209, 217, 231n–32n,250n–51n Deputy Assistant Secretary for Population Affairs (DASPA), 69, 12728, 233n, 238n, 252n. See also Mecklenburg, M. Deseret News, 119 Detroit, Mich., 252n Developmental effects on children of teenage mothers, 169-70, 173, 176-77 Diaphragm as contraceptive method, 121, 134, 237n Dienes, C. T., 88-89, 225n, 232n

Index District of Columbia, 122 Divorce, 31, 162, 171. See also Marital disruption Dixon, R. B., 162 Donovan, P., 123, 238n Dragastin, S. E., 228n Dryfoos, J. G.,214, 225n Duncan, G. J., 245n Earle, A. M . , 7 Early Periodic Screening, Diagnosis, and Treatment Program, 49 Edgar Allan Poe School, 245n Education, discrimination associated with pregnancy, 163-64; in early America, 6, 17-19, 162; vocational, 65, 166, 176, 186, 249n Educational attainment and childbearing, 163-64 Edwards, J., 13 Eisenhower Administration, 25 Eisenstadt v. Baird, 89 Eisman, S., 116-17, 123, 131-35, 137–48, 151, 153–55, 239n–42n Elder, G. H.,42, 228n Elster, A. B.,176, 243n Employment, adolescent, in early America, 18-19; programs for enhancing, 201-2, 249n-50n; trends in, 39 Engerman, S., 5 England, 10, 12-13, 15, 159, 218n Epidemic of adolescent pregnancy, xii, xvi–xvii, 22, 24–28, 37, 40, 47, 125, 164, 211, 220n-22n, 227n Erikson, K. T.,16 Erlenborn, J., xiii, 91-92 Essex County, Mass., 12-13, 44 Europe, 4-5, 7, 10, 14-15, 44-45 European marriage pattern, 7 Evaluation research, see Outcome evaluations Family planning clinics, characteristics of patients, 48-49, 110, 13334; and discontinuance rates, 106, 117; and increase in pregnancies, 78; male participation in, 169, 172;

277 parental notification requirement impact on, 131-56, 239n-42n; prevalence in the United States, 36, 88-89, 137; rate of adolescent use of, 36, 49. See also Family Planning Services and Population Research Act, Title X; Planned Parenthood clinics; School-based clinics Family Planning Services and Population Research Act, Title X, 33, 48, 56, 59, 62, 64, 68-69, 77-78, 8384, 87, 89–90, 93–94, 96–102, 11013, 121–23, 126–33, 139, 155, 214– 15, 223n, 225n, 232n–34n, 237n38n,242n–43n Fatherhood, and education, 169, 171-72; marital status and, 29-30; in past, 158-65; policies toward, 30-32, 165-79, 216-17; programs, 172, 176 Federal Register, 72, 87, 112-13, 119, 121-22, 131, 151, 155, 177, 234n36n,239n Fienberg, S. E., 244n Finch,R., 180 Flannery, T. A., 122–23 Fogel, R.,5, 218n Forbush, J. B., 61–63, 189–90, 227n, 229n Ford Administration, 50-51, 53-54, 66, 166, 229n-30n Ford Foundation, xiv, 193, 200, 203, 207 Ford, K., 148–49 Foreign-born, children of, 19 Forrest, J. D., 36, 49, 115-17, 123, 131-34, 137-48, 151, 153-55, 213, 215, 237n, 239n–42n Foster care, 52 Fourteenth Amendment, 89 Fox, G. L., 151–52 France, 5, 10 Fresno, Calif., 201 Fried, E., 164 Frisch, R. E.,4–6, 149 Fuller, C. L., 110–11 Furstenberg, F. F., 7, 18, 36-37, 116-17, 134, 152, 181, 183-84, 187-88, 195, 202, 205-8, 228n, 244n–46n,250n

278 Gasper, JoAnne, 243n Gershenson, C. P., 181 Girls Clubs of America, 115 Goldman, N., 213, 215 Goldmuntz, J., 174, 191, 194, 19697, 200-201, 205, 207-9, 249n-50n Gordis, L., 152 Gordon, L., 88, 225n, 228n, 232n Grady, W. R., 31, 142–47, 150, 243n Graff, H. J., 19 Great Society, 48 Greven, P. J.,8, 159 Grinker, W. J., 200, 202-3, 208, 253n Griswold, R. L., 162 Griswold v. Connecticut, 89 Grossberg, M., 162 Gurwitt, A. R., 158 Gutman, H., 5 Guttmacher, A., 89–90 Hajnal, J.,7 Hall, D. D., 159 Hanawalt, B. A., 218n Hannan, M. T., 244n Hareven, T. K., 19, 44, 228n Harlem, New York, 201, 202 Hartford, Conn., 183, 186, 201, 246n Harvard Population Center, xiii Hatch, O. G., 66, 81–82, 97–100, 110, 129, 175 Hathaway, W. D., 220n, 226n Hayakawa, S. I., 64, 66, 171-73 Hayes, C., 26, 35, 215–16, 225n Head Start, 189, 229n, 246n–47n Health Services and Centers Amendments Act, Title VI, 77–82, 84–86, 174-75, 187, 192-93, 196-200, 205, 208, 220n, 230n–31n, 246n, 248n-49n, 251n–52n; Title VII, 73, 75-76, 191, 230n-31n; Title VIII, 75-76, 230n-31n Heckler, M. M., 122 Heisler, T.,225n Helms, J. A., 68, 94–95, 225n–26n Hendricks, L., 243n Henshaw, S. K., 142-47, 213, 215 Herceg-Baron, R., 116, 134, 152 Heritage Foundation, 99 Hermalin, A. I., 142-47

INDEX Herpes, 213 Hertz, T.,250n Hindus, M. S., 10-16, 160-61, 219n Hiner, N. R., 18, 159 Hingham, Mass., 10-11, 219n Hirsh, M. B., 142 Hobson, B.,20, 219n Hofferth,S. L.,34, 221n Horn, M. C..,35 Howard, M., 181 Human Affairs Research Centers, 178 Human Resources Cabinet, 110 Hutchinson, A., 159 Illinois Association for Comprehensive Services to School-Age Parents, 167-68 Inazu, J. K., 152 Individual Participation Plan, 201 Initiation of sexual activity, delay of, 21, 63, 79-81, 83, 85-86, 118-19, 175-76, 212-13; in early America, 16, 163 Inter-Agency Services, Harford, 183, 186, 246n Inter-University Consortium for Political and Social Research, 190 Intrauterine devices (lUDs), effectiveness of, 38, 143; health risks of, 106; prevalence of use, 134, 241n Jackson, J., 227n Jaffe, F. S., 221n Jarvis Amendment, 32 Jeckel, J. F.,33,36, 49, 51, 167, 182-84, 186-90, 195, 202, 206-8, 224n, 244n–46n,250n,253n Johns Hopkins Program, 54–55, 58, 63, 82–83, 190, 232n, 247n Johnson Administration, 229n Johnson, F. E., 5 Johnson, L.,48, 96 Jones, A. H., 6, 7 Jones, D. L., 9, 159 Jones, E. F., 213, 215, 241n Jones, R. M.,225n Joseph P. Kennedy, Jr. Foundation, 33–34, 40, 61–63, 76, 82, 165, 227n, 230n

Index JRB Associates, 50, 76, 188–91, 207, 243n, 247n Juster, S. M., 18, 242n Juvenile courts, 163 Kaestle, C. F., 17, 219n Kahn, J. R., 200-203, 206-8, 253n Kahn,J. S.,243n Kantner, J. F., 9, 34-35, 41, 134, 142, 144, 146-50, 164, 228n, 240n Kasun, J. R.,227n Katz, M. B.,243n Keen, N., 142 Kennedy, D. M., 88 Kennedy, E. M., xvii, 23, 33, 50-57, 64, 67-68, 77, 79, 81-86, 95, 16566, 171-72, 175, 204, 220n-21n, 223n, 225n, 227n Kenny, A. M., 115-16, 237n Kerber, L., 160 Kelt, J. F.,1, 159, 228n Kimmich, M. H., 174, 191, 194, 19697, 200-201, 205, 207-9, 249n-50n Klerman, L. V., 49, 51, 165, 182-84, 186-87, 195, 202, 206-8, 243n46n, 250n, 253n Klinman, D. G., 243n Kuhn, A. L., 161 Lader, L., 88 Lamb, M. E., 158, 243n Landale,N. S., 31, 243n Landman, L. C., 88 Lasiett, P., 4, 10, 14,45 Legitimation, determinants, 29, 202; in early America, 10-11, 13, 158, 160-61, 163, 219n; educational attainment following, 170–71; policies toward, 30–31, 166–67, 17072, 177–78; racial/ethnic patterns of, 29–31; rates of, 28–29, 31, 48 Leridon, H., 142, 144–45, 149 Levy, S. B., 200, 202-3, 208, 253n Lewis, J., 218n Library Court, 81 Life course perspective, 41–44, 228n Life Support Centers Act of 1975, 53 Lincoln, R., 213, 215, 227n Littlewood, T. B., 48–49

279 Lockridge, K. A., 8, 159 Longo, K. R., 243n Los Angeles Times, 118 Lowe, C., 229n Lutherans for Life, 115-16 McArthur, J. W . , 5 McCarthy, J., 221n McCathren, R. R.,50 McCloskey, P., xiv McLaughlin, S. D., 31, 221n, 243n McLoughlin, W. G., 219n Malmsheimer, L. M., 160 Mann, D., 116, 134 Mann, H., 19 Margaret Hudson Program, 190 Marital disruption, 167, 170, 186-87 Marital stability, adolescent parenthood implications for, 31, 167, 170, 186-87, 243n, 246n Markowitz, M., 152 Marriage, in early America, 4, 7-9, 15-16, 21, 158-61, 218n-19n; negative effects of early, 18, 177-78; prevalence among teenagers, 2832, 48, 86, 137; in Western Europe, 7, 218n. See also Legitimation Martin, E., 100, 233n, 238n Maryland, 218n-19n Mason, K., 19 Mason, W. M., 244n Massachusetts, 8, 10, 12-13, 15, 44, 89, 159, 219n Maternal and Child Health Service, 53 Maternal and Child Health Services Block Grant, 77, 85, 196 Maternal and Infant Care and Youth Program, 49 Maternity home, 50 May, D., 162 May, E. T., 162 Mecklenburg, M., xiv-xvi, xviii, 50, 63, 76-77, 84, 87, 99, 102-9, 11819, 121,126-30, 178, 192,196, 213, 222n, 227n, 229n, 231n, 233n37n, 243n, 247n, 249n, 25In Media, approaches to preventive interventions, 214; and parental

280 notification, 117-19, 125, 237n; treatment of sexuality, 86, 212-13 Medicaid, 30, 49, 53, 95, 100 Menarche, age at marriage and, 7–9; in early America, 4–9, 11, 21, 218n; in Europe, 4–5,9; nutrition and, 5-6; slaves and, 5-6; subfecundability and, 7, 11, 149-50 Menken, J., 143-47, 150, 221n, 226n Middlesex County, Mass., 13 Miller, W. B., 152 Miniature adults, 17 Mnookin, R. H., 232n Moffet, T.,83 Mohr, J. C., 16, 88, 161 Montague, R., 34, 227n Moore, K. A., 7, 18, 30, 34, 41, 164, 221n, 226n Moral Majority, 116 Moran, G. F., 158, 160, 219n, 242n Morgan, E. S., 11 Morgan, S. P., 184, 187, 195, 205-8, 228n, 244n-46n, 250n Mosher, W. D., 35 Mosteller, F., 131 Mother-daughter relationship, 15152 Moynihan, D. P., 131 Murray, C., 229n National Academy of Sciences, xii, 216 National Alliance Concerned with School-Age Parents (NACSAP), 49-50, 61-63, 165, 189-90, 224n, 227n, 229n, 245n National Conference of Catholic Bishops, 82, 116 National Conference of Catholic Charities, 79-80, 116, 227n National Family Planning and Reproductive Health Association (NFPRHA), 113, 122, 126-29, 131, 233n, 235n, 238n National Institute for Child Health and Human Development (NICHD), 41, 60, 66, 86, 170, 207, 236n, 247n National Organization for Women (NOW), 115

INDEX National Right to Life Committee, 233n National Survey of Family Growth, 142-43 National Urban League, 115 Natural family planning, see Rhythm method of contraception New, T., 225n New England, 4, 8, 10-11, 13-14, 17, 21, 158-59, 218n-19n New Haven, Conn., 57, 182-88, 195, 202, 206-7,244n-46n New Mexico, 176 New York State, 91, 122 New York Times, 81, 83, 100, 112, 118, 120, 237n Nix, L. M., xvii, 50-51, 70, 72-77, 85, 173-74, 192, 196, 198, 229n31n, 247n Nixon Administration, 229n Nixon, R., 48, 90, 96 Nonmarital childbearing, attitudes towards, 28-29, 159-60, 219n; determinants, 29-30; in early America, 10, 13-14, 44-45, 158-61, 219n; race differences in, 29; rate among adolescents, 28-29, 38-39, 164, 222n; in Western Europe, 44-45 Norton, D.,26, 221n Norton, M. B., 160, 243n Norton, S. L., 9, 159 O'Connell, M., 29 Office of Adolescent Pregnancy Programs (OAPP), xiv-xviii, 47-50, 70-78, 84, 86-87, 127, 173-80, 182, 188-200, 203-5, 207, 229n31n, 233n, 243n, 246n-53n. See also Mecklenburg, M.; Nix, L. M. Office of Child Health Affairs, 230n Office of Economic Opportunity (OEO), 89 Office of Family Planning Programs, 41, 100, 128-29, 213, 238n Office of Health Planning and Evaluation, 75, 191 Office of Management and the Budget (OMB), 56, 121, 248n Office of Planning and Evaluation, 55-56, 75, 191-93, 196, 209, 247n48n, 250n

Index Office of Population Affairs, 60, 87, 116, 119-20, 230n, 234n-38n, 242n-44n Olsen, T. D., 176 Omnibus Budget Reconciliation Act of 1981, 84, 114, 232n Oosterveen, K., 10, 14, 45 Oral contraceptives, see Contraceptive pills Orr, M. T., 141, 241n Ory, H. W., 215 Outcome evaluations, of adolescent fatherhood programs, 176; of comprehensive care programs, 49, 52, 58, 60-61, 68-69, 71-76, 85-86, 180-210, 217; control groups in, 181, 183-84, 190-91, 200-201, 205-6, 244n; of family planning programs, 181, 214-15, 243n-44n; impediments to performing, 20410, 228n; of programs to delay sexual activity, 79; of Project Redirection, 200-203, 206-7; statistical techniques employed, 41, 184, 195-96, 201-2, 206, 250n Parent-child communication, 134, 219n. See also Mother-daughter relationship Parental consent, 52, 90-93, 100102, 111 Parental notification, controversy over, 38, 68-69, 80, 83, 87, 90, 93130, 154-56, 225n-26n, 233n-38n; impact on adolescents, 131-56, 239n-42n Parkes, H. B., 16 Paul, E. W.,91 Paul, L., 241n Perlman, J., 235n-36n Peterson, E., xvi, 127, 234n, 238n Phoenix, Ariz., 201-2 Physiology of Marriage, 15-16 Pilpel, H. F., 90-91 Piotrow, P. T., 232n Piven, F. F., 243n Planned Parenthood clinics, 133-34, 240n. See also Family planning clinics; School-based clinics Planned Parenthood of Central Missouri v. Danforth, 91-92

281 Planned Parenthood Federation of America v. Heckler, 123 Planned Parenthood Federation of America v. Schweiker, 122-23 Planned Parenthood Federation of America (PPFA), xiv, 40, 51, 62, 89, 113, 122, 125, 127, 129, 131, 133, 152, 235n, 24()n Polgar, S., 164 Polit, D. F., 200-203, 206-8, 253n Pomeroy, R., 88 Population Council, 244n Poverty, culture of, 45, 226n; and family planning programs, 48-49, 88-89, 96-97, 112-13; nonmarital childbearing correlated with, 185, 187; in past, 163, 243n Pratt, W. F.,35 Pregnancy, adolescent, number and rate of, 24-25, 221n; in early America, 10-16; parental notification requirement impact on, 131-56, 239n-42n; repeat, 186, 201-2, 244n Pregnancy intention, 33-34, 36, 38, 62, 187-88, 224n, 246n Pregnancy resolution, trends in, 164. Seealso Abortion; Adoption; Legitimation; Nonmarital childbearing Presser, H., 170 Private physicians, contraceptive services, 88, 106, 214, 240n-41n; in early America, 6, 15-16, 18; parental notification and, 90, 101, 103, 113-14, 139-41, 149,240n "Pro-Choice," xiv, 39, 226n-27n "Pro-Life," xiv, 39, 77, 81, 94, 102, 127-28, 226n-27n, 233n-34n Project Redirection, 194, 200-203, 206-8, 253n Prossner, B., 250n Prostitution, juvenile, 20 Puberty, association with initiation of sexual activity, 149 Public assistance, to female-headed families, 49, 158, 164; in past, 3839, 163. See also Aid to Families with Dependent Children; Welfare; Welfare dependence Puritans, 3, 11-12, 17, 21, 158-60, 219n

282 Race and ethnic differences, nonmarital childbearing, 29-31; and parental notification requirement, 115; sexual activity of teenagers, 34-35 Rainwater, L., 131 Reagan Administration, xii-xiii, xivxviii, 42, 68, 77, 81, 87, 95, 97-99, 106-7, 113-21, 124, 126-28, 130, 132, 154, 157, 177, 179, 191,211, 213, 215-17, 231n, 237n-38n Reagan, R., xiv, 76, 79, 85, 95-96, 98-100, 110-12, 175, 229n, 233n, 235n Reed,J., 88, 225n, 232n Religion, in early America, 11-13, 15-16, 20, 158-62, 219n; and sex education programs, 65, 78; and values, 78 Republicans, xiii, 76-79, 81, 85, 9597, 121, 237n Research needs, 37-46, 56, 79-80, 83, 86, 175-77 Rhythm method of contraception, 134, 140-41, 145, 216 Richardson, E., 229n Richmond,:., 32, 219n Riverside, Calif., 201-2 Rogers, C., 29 Rogers, P. G., 58, 94-95, 232n Rosen,:. L.,243n Rosoff, J. I., 39, 96, 213, 215 Ross,:. M., 158 Rothman, D. :., 163, 219n Rothman, E. K . , 9 , 161 Rutman, A. H., 218n Rutman, D. B., 218n Ryan,M. P., 162 Ryder, N. B., 38, 148 Sagi, A., 158 San Antonio, Texas, 201, 253n Sander,:. H., 243n Sanger, M., 88 Scandinavia, 5 Scheuer, :., xiii, xiv, 69, 95, 224n25n, 230n, 232n Schirm, A. L., 143-47, 150 Schlossman,S., 16, 163 School, dropping out of, after preg-

INDEX nancy, 31, 39, 48-49, 74-75,16364, 167, 186; determinants of, 184; in early America, 6; marriage and, 170-71 School-Age Mother and Child Health Care Act of 1975, 47, 50-54, 5758, 66, 68-69, 86, 165, 168, 223n, 230n School-based clinics, 214-15 Schuck, P.,55

Schweiker, R. S., 61, 66-68, 77, 97, 99-100, 102, 108-11, 115, 118-19, 121, 127, 233n, 235n, 237n Scott, S. W., 15

Second Great Awakening, 161 Secretary of Health and Human Services, 55, 70, 84, 101, 223n; see also Califano, :. A.; Schweiker, R. S. Sedlack, M. W., 16, 164 Self-esteem, 63 Service Delivery Improvement (SDI), 243n-44n Sex education, content and comprehensiveness of, 65, 78; effectiveness of programs, 214; parental role in, 65, 78; policies toward, 5354, 57, 59, 65, 69, 74-75, 222n24n Sexual abuse of adolescents, 112, 151, 241n-42n Sexual activity, attitudes about, 8083, 124-25, 164, 221n-22n; in early America, 9-16, 19-20, 15963; in England and France, 10, 1215; frequency of intercourse, 35, 144-45, 148, 241n; nature of problem, 42, 124-25; racial/ethnic variation in, 34-35; rates among unmarried teenagers, 9, 34-35, 78, 164, 213 Sexual intercourse, see Initiation of sexual activity; Sexual activity Sexually transmitted disease, 112, 213 Shah, F. K., 35 Shea, P., 116-17, 134, 152 Shepherd,:. P., 7 Shorter, E., 14-15, 159 Shot-gun marriage, 170 Shriver, E. K., 34, 40, 52, 61, 84,

Index 165, 186, 204, 223n–24n, 227n, 230n Shriver, S., 36,54 Sinai Hospital, 182–83 Smith, D. B., 218n Smith, D. S., 10–16, 160–61, 218n– 19n Smith, R. M., 10, 14, 45 Smith–Rosenberg, C., 161 Sociometrics Corporation, 249n Soltow, L., 6 Sonenstein, F. L., 174, 191, 194, 196–97, 200–201, 205, 207–9, 249n–50n Sopper, D., 166 South, 218n Spermicides, 134, 140–41, 145 Squeal Rule, 236n Stafford, R. T., 66–67 Stannard, D. E., 17 State of N.Y. v. Heckler, 123 State of New York Department of Health, 122 Steckel, R.,5–7 Steiner, G. Y.,228n–29n Steinfels, M. O., 228n Sterilization as contraceptive method, 38 Stevens, E., 6 Stiles, H. R., 14 Stine, O. C., 164 Stone, L . , 7 , 10, 12–13, 159 Storer, H., 6 Sutch, R., 5 Sweet, L. L, 162

T. H. v. Jones, 92

Talwar, P. P., 7 Tannen, M. B., 200–203, 206–8, 253n Tanner, J. M., 4 Teenage Pregnancy Objective, 230n Teitelbaum, M., xii Television, advertising of contraceptives, 214; sexual programming, 212–13 Thernstrom, S., 19 Thompson, R., 11, 13, 18, 218n Tieze,C.,221n Tilly, L. A., 15

283

Torres, A., 36, 49, 115–17, 123, 131– 35, 137–48, 151, 153–55, 237n, 239n–42n Tracy,P. J., 13 Trattner, W. I., 243n Traugott, M. W., 227n Triton, 189, 247n Trussell, J., 5–7, 143–48, 150 Tuma, N. B.,244n Ulrich, L. T., 14, 160 United Families of America, 116 University of Maryland, 170 University of Michigan, xiii–xiv Urban and Rural Systems Associates (URSA), 199, 228n, 252n Urban Institute, 30, 75, 174–75, 191– 200, 205, 207–9,248n–52n U.S. Bureau of Census, 44 U.S. Congress, House: Committee on Education and Labor, 32–33, 58–59, 71, 180, 220n; Committee on Energy and Commerce, 98, 108–11, 117, 132, 152, 176, 196; Committee on Interstate and Foreign Commerce, 58–59, 90, 95, 113–15, 173, 220n, 224n–25n, 230n; Select Committee on Population, xiii–xvi, 30, 36–38, 59–60, 69, 92–93, 169–70, 216. 219n–22n, 226n–28n, 230n,233n,243n,246n U.S. Congress, Senate: Committee on Government Operations, 232n; Committee on Human Resources, 33, 57, 60–67, 77, 168–69, 171–72, 223n, 226n, 247n; Committee on Labor and Human Resources, 78, 81, 84, 97, 175, 199, 220n, 227n; Committee on Labor and Public Welfare, 49–52, 165–68, 229n, 232n U.S. Congress, 91st, 90 U.S. Congress, 95th, xiii, xvii, 22–42, 47_48, 64, 67, 69, 173, 188, 205, 219n, 222n, 224n–25n, 246n–47n U.S. Congress, 96th, xv, 37, 42, 115. 230n U.S. Congress, 97th, 48, 105, 123 U.S. Department of Justice, 124 U.S. Department of Labor, 200

284 U.S. Department of State, 89 U.S. Supreme Court, 89–92, 124, 164 Utah, 100, 176 Utah College of Medicine, 176 Valentine, J., 229n, 247n Vaughn, B., 142 Vaughn, J., 51 Venereal disease, 112, 237n Vinovskis, M. A., 3, 8–9, 17–19, 21, 44, 88, 155, 158–60, 162–64, 168, 179, 219n–21n,224n–28n,230n– 31n,234n–35n,239n,241n–43n, 252n Voight, M., 15, 18 Volkmer, H. L., 93–94, 107, 109, 121,233n Waite,L. J., 221n Wall Street Journal, 119–20 Wallach.H. C., 163 Wallach, S., 16 Walloe, L.,4 Wallop, M., 68 Walsh, L. S., 218n–19n Walsh, M. R., 6, 18 Walton, G. M.,7 Warner, S. B., 161–62 Washington Memo, 54, 77, 84, 97, 232n, 238n Wallenberg, B. J., 39 Wattleton, F., 62 Waxman, H., 77, 81–82, 84, 97, 111, 113–14, 209 Webster School, 49, 164–65, 181–82 Wechsler, N. F., 90–91 Weeks, J. R.,31,48 Weitzman, L. J., 162 Welfare, benefit levels, 38–39; expenditures to adolescent mothers, 30, 38–39, 41, 59, 67, 94, 158, 164,

INDEX 177, 222n–23n. See also Aid to Families with Dependent Children Welfare dependence, 185 Wells, R. V., 3, 160 Wenk, D. A. L.,34, 221n Werker, H. C., 122 West Virginia, 176 Western Europe, 213 Westinghouse Learning Corporation, 189, 246n–47n Westoff, C. F., 38, 148, 213,215, 241n White, W. J., 100, 127–29, 233n, 238n White House, 24, 85–86, 110–11, 124 WIC, 191, 249n Williams, H. A.,60, 220n Williams, P. R., 31 Wilmington News Journal, 77 Winges, L. D.,31,243n Winston, D. A., 99, 102 Wise, L. L.,7, 18, 221n Withdrawal as contraceptive method, 35, 88, 134, 141, 145 Work Incentive Program (WIN), 201 Wulf, D.,213, 215 Wyshak, G., 4–5, 149 Yale University, 33, 182, 208 Yancey, W. L., 131 Young Mothers Program, New Haven, 182–88, 195, 202, 206–7, 244n–46n Youth Health Services, 176 Zabin, L. S., 142, 144–45, 147, 150 Zelnick, M., 9, 34–35, 41, 134, 142, 146–50, 164, 228n, 240n Zero Population Growth, 227n Zigler, E. F., 229n, 247n Zimring, F. E., 232n Zinaldin, J. S., 162