One of the nation's great success stories of the past two decades is in danger of unraveling, according to the National Campaign to Prevent Teen and Unplanned Pregnancy. "After impressive declines nationally in all 50 states and among all racial-ethnic groups, progress in preventing teen pregnancy and child bearing has come to a virtual standstill," says Bill Albert, the Chief Program Officer for the National Campaign.
The teen pregnancy rate in the United States peaked in 1990, Albert says, and declined every year through 2005. In those 15 years, the teen pregnancy rate dropped 37%, but those numbers have begun to creep in the other direction, according to the newest data available. Between 2005 and 2006, the pregnancy rate among teens increased a full 3%.
America has the highest teen pregnancy rate of any Western industrialized country, and within certain racial and ethnic groups, the numbers are disproportionately high. Among Hispanic/Latina teen girls in the United States, 53% get pregnant at least once before the age of 20, according to the National Campaign. Among African American teen girls, the figure is 51%; for white, non-Hispanic teens, it's 19%.
"One way to look at it is to say that more Latino and African American teens get pregnant than don't. If that isn't alarming, if that isn't a call to action, I am not sure what is," Albert says.
Loretta Ebison, M.A., M.F.C., L.P.N., is the Adolescent Parenting Program (APP) coordinator for the Beaufort County School District in North Carolina, a statewide initiative of the Department of Health and Human Services. Seventy-five percent of the program's participants in her county are Hispanic/Latina or African American. "It saddens me," says Ebison, who is African American. "That is why I think education is very important. We need to discuss these issues before a teen experiences a pregnancy."
As outlined by the National Campaign, teen pregnancy is linked to a number of other social issues:
"When you look at the challenges of teen pregnancy and child bearing, the glass-half-full interpretation, which is true, is we have made extraordinary progress as a nation," Albert says. "The glass-half-empty interpretation, which is also correct, is that despite this enormous progress, our rates in this country nationally and by race and ethnicity are out of whack with the rest of the industrialized world."
Ebison is one of many nurses who have made it their mission to work with teen moms. Nationwide there are programs being run and/or staffed by nurses who help pregnant and parenting teens in their efforts to become self-sufficient through education on a variety of issues, from parenting to job skills.
In the APP, a nurse or social worker visits each teen one-on-one, 12 times a year, with eight of those visits occurring in the teen's home. The program can provide resources for up to 25 students in each of its funded institutions. It aims to improve the development of the participants' children by increasing their number of healthy births as well as by providing resources to improve their age-appropriate physical, emotional, cognitive, and social development. The APP also offers at least 25 hours of educational group instruction annually.
"When I am working one-on-one with the girls, I feel fulfilled," says Ebison, who was a teenage mom. "I feel like I am doing what I was called to do. At the end of the day, if I feel like maybe I prevented one girl from having a secondary pregnancy and maybe I helped one girl decide to stay in school and go to college [I feel good]. That is my ultimate goal, because I understand that without a college degree you are going to have a tough time."
Ebison's home state of North Carolina enacted the Healthy Youth Act in 2009, requiring comprehensive sex education in schools. "Before, we were abstinence-based schools...but obviously they are [having sex]. I think it is important to find the teen where they are; whether they [practice] abstinence or they may be having sex, and we can address it either way now," she says.
One national program serving vulnerable first-time mothers and low-income families is the Nurse-Family Partnership (NFP), an evidence-based community health program. It partners young mothers with a registered nurse during pregnancy and coordinates home visits that continue through the child's second birthday.
The NFP program that runs out of North Central Community Health Center in St. Louis, Missouri, works with 100 families. The median age of the mothers is 19, and 85% are minorities, according to program supervisor Vanessa Davis, B.A., R.N. Once enrolled, participants see a nurse weekly for four weeks and then every other week until the baby's birth. By working with the women during pregnancy, Davis says, the nurses can change the course of a potential negative outcome. "We make sure she gets that prenatal care...and educate her on nutrition." After delivery, the visits are weekly for six weeks and then return to bi-weekly. "We build strong relationships and are the support person for them," says Davis.
NFP goals include long-term family improvements in health, education, and economic self-sufficiency as well as help with planning future pregnancies. "The last piece is finding out what is this mom's heart's desire. ‘What do you see yourself doing in the future and how can we help get you there?' We talk about those future goals," Davis says.
The NFP has observed a number of positive outcomes in 30 years of research from various controlled trials. In at least one of the trials of the program, the following outcomes were observed:
Today, NFP serves first-time moms and their babies in 32 states. The New York City chapter is the largest NFP urban site in the nation. Any low-income, first-time expectant mother can enroll, regardless of age or immigration status, if she lives in a zip code served by NFP, and is less than 28 weeks pregnant. All teens under 18 are eligible.
The NYC NFP had 2,313 active clients as of July 31, 2010; it hopes to increase that figure to 3,015 by 2011. The median age of clients is 20, with many who first became pregnant as teens. Forty-three percent are African American, 42% Hispanic, 8% multi-racial, 4% Asian, and 3% white/non-Hispanic.
Beatriz Lugo, R.N., C.L.C., is the NFP program coordinator at Harlem Hospital Center, which covers East, West, and Central Harlem; Washington Heights; and Inwood. Lugo's clients are primarily minority teens. Lugo, who is of Hispanic descent, says there is great diversity in that ethnic population. "Hispanics are a mix of many races. Many of the clients I have are from the Dominican Republic and Mexico," she says. "In these countries they are usually allowed to get married at age 14. Many of them have been married in their country. With a lot of minorities, it is part of their culture [to have children young]." Many of these teens have family in countries outside the United States, but they don't have anyone to turn to here. That scenario makes NFP so critical. "With the involvement of a nurse, they are more likely to stay in school," says Lugo, who became a mother at age19.
Enrolling teens while they are pregnant gives nurses time to build trust with clients. "For teenagers, pregnancy is not just about pregnancy; it is about dealing with their futures," Lugo says. "Oftentimes clients don't see the baby as a baby or an individual until the baby moves. We teach them to bond with the baby [while they are pregnant]."
Organizations like the NFP provide more than clinical care and guidance; they also try to give the teens hope. "Sometimes they feel hopeless. They didn't plan this pregnancy. We have to give them support. In terms of family relationships, we will work with it," says Lugo, who has a caseload of 25 clients. Fathers and other family members are also encouraged to take part in the program. "Sometimes it is the grandmother who is there and we will work with her.... We make mom #1, but we allow these [other family members] to be part of it."
The biggest challenge for teen moms is education. "Many stop school," Lugo says. "We have to incorporate in our teaching that just because you have a baby doesn't mean you cannot go back to school. We guide them to daycare centers and the support they need."
The New York City Department of Education operates 38 Living for the Young Family Through Education, or LYFE centers, mostly in high schools. Each LYFE site has a childcare center and is linked to a social services and health referral network. Last year 21 of Lugo's clients graduated from the program.
Another successful pregnancy support program for high school students can be found in the Brownsville Independent School District (BISD), on the southern-most tip of Texas on the Mexican border. Run primarily by nurses, BISD won the 2008 Broad Prize for Urban Education and a $1 million award (the largest education prize in the country) as the most improved urban school district. The Broad Prize also recognizes schools that reduce achievement gaps affecting poor or minority students.
Among its 57 schools, BISD has seven high schools and three alternative schools, including the Lincoln Park School for pregnant and parenting teens. "It is an alternative school of 150 girls, which can fluctuate, and its [population] is 99.9% Hispanic," says principal Hector Hernandez. Lincoln Park also offers an accelerated program.
Outreach worker Vici McClure, R.N., travels to the district's middle and high schools. She worked as the Lincoln Park school nurse for 13 years. McClure says culture and the media play a role in teenage pregnancy in the district. "The things that the kids see, everything that bombards them through the media, makes it kind of acceptable to them. There is no stigma to it any more," McClure says. "People just accept the fact, assimilate that child into the family, and they just go on. There are no consequences [for the pregnancy]. There are the welfare programs and government programs that help the child take care of her child, making it much easier than it was 25 or 30 years ago."
But that doesn't mean it is easy for teen mothers. School attendance can be an issue for pregnant and parenting teens. "If a kid complains they are sick, I try to keep them here on campus as much as possible," says Martha Ledezma, R.N., the school nurse. "I may say to them, ‘You are pregnant. Nausea comes with pregnancy.' I try to let them rest."
The school has a licensed daycare center, and sick children must be sent home. "Unfortunately, if the baby has to go home...nine out of 10 times the mom is going home with that baby," Hernandez says.
Lincoln Park became an alternative school in 1991. Since then, 500 girls have graduated. Some pregnant teens choose to stay at their home campuses, rather than travel to Lincoln Park, although pregnant middle school students are strongly encouraged to enroll at the alternative school. Lincoln Park offers two parenting classes: one that deals with pregnancy through birth; the other, with the first five years of childhood. The school nurse is very involved in those classes. "They learn parenting skills, good nutrition for their baby, safety issues, well baby visits, anger management, how to deal with a toddler, and teaching a toddler," McClure says.
The outreach program is in its third year, and its numbers have steadily increased from 100 to 140 to 200 young women. McClure does one-on-one and small group sessions before school, after school, or during the lunch period. "On their home campuses they are not required to do parenting classes, so it is possible that they do not get anything unless we do something supplemental for them. We are also working toward getting a pregnancy prevention curriculum in place at the middle school level," McClure says. "That is a big goal we have."
Nationwide there are also many local agencies, headed and staffed by nurses, working with pregnant and parenting teens. Pernet Family Health, based in Worcester, Massachusetts, the second-largest city in New England, is a major provider of home health care and early intervention services to families in the area. The agency's roots date back to 1955 when the Little Sisters of the Assumption came to the city to provide health care and support to disadvantaged families and to revitalize the spirit of those degraded by poverty. The agency, named after its order's founder, is certified by the Massachusetts Department of Public Health.
Stephanie Omuemu, B.S.N., R.N., works for Pernet in the Worcester Healthy Start Initiative. Over the past 15 years, Worcester has had a higher infant mortality rate than that of Massachusetts and the nation. The program aims to reduce infant mortality and improve the birth outcomes for high-risk populations. Eligible mothers, some of whom are teens, receive a case manager and a nurse who provide assessments and resource referrals.
Omuemu, who is of Nigerian descent, and another nurse share a caseload of 90 families. Approximately 90% are minorities. "Our program deals with immigrant populations and African and Spanish populations. That is the majority of our caseload," Omuemu says. "They are new to this country, haven't received their full citizenship yet, or maybe some of them are on green cards . . . or starting the citizenship process." Teenage moms head about 20% of the families.
Omuemu visits clients in their homes and at Pernet's office. She says there are many challenges to working with teenagers. "When they are not showing, they don't grasp the fact that they are pregnant. They will take the test and they will see that it is positive, and then they will go to the doctor. But until the baby starts to be very visible and they can feel the baby moving, I think they sort of disconnect. They seem to think, ‘Okay, this is something that is going to happen, but it is way in the future.' They do not see that they need to prepare for this now."
Getting the teenagers to attend birthing classes is also difficult. "I tell them that knowledge is power. If you go to the class you will know exactly what is going to happen, and you are going to feel more in control," Omuemu says.
Omuemu became a nurse, in part, to work with minority populations. "My goal, which is a very large one, is to eliminate health disparities within vulnerable communities, within racial and ethnic groups. Health care should be universal. It is not something that only certain people should have," she says."Being of Nigerian descent and coming from what would be deemed a vulnerable population, I know what it is like. I have lived it. I know how scared one can be of the system. I know how difficult it is to assimilate to this country, learn the culture, and still try to maintain your culture as much as you can. I am aware of the problems."
Pernet offers an early intervention program as well, which provides family-centered developmental services to children aged two months to three years who are experiencing or are at risk of developmental delay. Miriam E. Torres, R.N., a clinical child developmental specialist for Pernet, has been a registered nurse since 1980. She says about 50%–60% of the children she works with were born to teen mothers. Approximately 30% are minorities. Torres visits clients at home and works on the child's development, alongside parents, through play.
Torres says her background can be an asset or detriment when working with some minorities. "They can be feeling comfortable because I speak their language and I understand what is going on," she says. "Or they could feel threatened because...I understand the conversation and the surroundings."
While teenage pregnancy is associated with a host of challenges, it can also inspire the young mother. "Sometimes it gives them the incentive to better themselves," Torres says. "I have had teen moms who have gone on to be lawyers."
Ledezma, who grew up in the Texas district she now serves, uses her Hispanic background to inspire and connect with her students. "I let them know that they need an education. They need to apply themselves," she says. "I am a nurse and I show them that you can come from anywhere and be anything. I am 27 years old and I became a nurse at 21. As a minority nurse I am showing them I did it and they can do it."
Many nurses of color say their own ethnic or racial background has a positive influence on their practice. "To be able to give back to your own personal ethnic group, it is a bonus as well. In turn, it helps out the community that you may be involved with or part of," Davis says. "I am able to share cultural experiences with my own personal team, with the nurses I work with. That is beneficial too because the more diverse it is, the you are able to pull in those different pieces to make the best outcome for the client. You are able to come up with creative and innovative ideas, keep these teen moms involved, wanting to come, and wanting to change."