Addressing Teen Pregnancy and Early Parenting among Youth in Foster Care
SEPTEMBER 2020
Marleen Milner, Ph.D., MSSW
Southeastern University mmilner@seu.edu
Adolescent pregnancy has been studied extensively since the 1970s when the long-term impacts on the well-being of both the teens and their children came to national attention.1 Although the national rate of teen pregnancy has declined substantially since the 1990s, youth in foster care continue to have a significantly higher risk of becoming pregnant and giving birth during their teen years. Efforts to reduce risks and strengthen factors that contribute to the resilience of teen parents and their children have significant potential to impact the futures of those in this vulnerable population.
Scope of the Issue Definition. Researchers define teen pregnancy as a pregnancy that occurs between the ages of 13 and 19 years. Most studies assess rates of pregnancy to youth between ages 15 and 19 years, and births until the age of 20 or 21 years. Prevalence. Concerted efforts to address and prevent teen pregnancy have resulted in a steady and dramatic decline over the last 30 years. Births to youth between 15 and 19 years declined 72 percent between the peak year of 1991 (61.8 births per 1,000 teens) and 2018 (17.4 births per 1,000).2 In Florida, the birth rate in 2018 was slightly lower, at 16.7 births per 1000 teens in this age bracket, and 80 percent of these births were to older teens between the ages of 18 and 19 years.3 Despite these encouraging developments, youth in foster care, a population already at very high risk for experiencing myriad adverse outcomes have a substantially higher probability of experiencing teen pregnancy and early parenting. A rigorous longitudinal study of more than 700 youth in the Midwest by Dworsky and Courtney (2010) found that youth in foster care or transitioning out of the foster care system were two and a half times more likely to experience pregnancy by age 19. Forty-six percent of these youth experienced a repeat pregnancy, compared to 34 percent of their peers in the general population.4 Another influential study by Courtney et al. (2007), which was based in California, found that one-third of female participants emancipated from the foster care system experienced pregnancy before the age of 18 years, and nearly half of participants by age 19. This rate was twice that of a national sample of youth of similar racial backgrounds who were not involved in the foster care system.5 A follow-up study linking foster care and birth records in California between 2003 and 2007 found that more than 25 percent of teen girls who were in foster care at the age of 17 gave birth before age 19; of these, more than 30 percent had a second child before age 20, and of those whose first birth occurred before age 18, 40 percent had a second teen birth.6
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Risk Factors. There are multiple risk factors correlated with early pregnancy and teen parenting that put youth with a history of foster care at increased risk. These include risk factors which impact this population disproportionately, such as a history of physical, emotional, and sexual abuse or neglect.7 A history of maltreatment significantly impacts the likelihood of teenage pregnancy and birth.8 After controlling for income, minority status, and family structure, Noll and Shenk (2013) found that adolescent girls with a history of maltreatment were two times more likely to give birth between their 14th and 19th birthday. Sexually abused or neglected girls had the highest birth rates among those who experienced maltreatment.9 Sociodemographic factors such as race/ethnicity, poverty, poor parental educational outcomes, family disruption, and impoverished neighborhood settings are additional factors that increase the risk of early pregnancy and are more likely to exist among families involved with child protective services (CPS).10 Race and ethnicity significantly predict teen childbirth, with Latina, Black, and Native American girls more likely to give birth than their Caucasian peers.11, 12 Although research has consistently indicated that youth in foster care are at a significantly higher risk for early parenting, including repeat pregnancies, the sheer number of overlapping risk factors within this population has made causal relationships challenging to ascertain. In a longitudinal, population-based study involving over 30,000 girls, King and Wert (2017) found that the highest birthrates occurred among teens who entered foster care between the ages of 13 and 14 years or were Latina (54%). Other risk factors included being in state custody for less than twelve months, placement instability, living in congregate rather than foster care settings, and having a history of running away.11 Many studies found that females involved in the foster care system as older adolescents or who aged out of the system were at higher risk than those with a history of foster care at an earlier age.4, 11, 6 Young women whose first births occurred before the age of 18 were also at a much higher risk of having a repeat birth by the age of 21. Despite research linking foster care system involvement to a higher risk for early pregnancy and parenting, co-occurring risk factors and contradictory results in other studies make it difficult to determine the nature of the relationship between foster care placement and teen pregnancy.11 A recent study by Font et al. (2019) attempted to tease out whether the higher risk of early motherhood reflected sociodemographic and family structure factors as opposed to involvement with foster care or CPS. While the researchers found that youth in foster care were at significantly higher risk, they concluded that CPS and foster care system involvement were not causal factors. Instead, they argued that when all factors were considered, CPS and foster care placement may reduce the risk. This conclusion was based on the finding that early births were “higher before CPS involvement or foster care placement than during or after these experiences� (p. 281).10 In addition, girls who reunified with their families were found to be more likely to become pregnant than those placed with non-kin guardians or adoptive placements. Dworsky and Courtney (2010) found that remaining in care after the age of 18 is a protective factor rather than a risk factor. Youth who stayed in care experienced a 47 percent reduction in the expected rate of pregnancy between the baseline interview and the interview at age 19. That risk was lowered by 55 percent among young women in a group care placement. While the reasons for this reduction in risk were not clear, Dworsky and Courtney (2010) speculated that increased supervision and relationships with caregivers who discouraged risky behavior and encouraged positive activities might contribute to this finding. Similarly, Font et al. (2019) found that girls in nonrelative family care or who exited to adoption or legal guardianship had a significantly reduced risk, compared to those who reunified with their birth parents.
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Consequences. Research demonstrates that teen parenting is associated with significant educational, economic, and emotional consequences. Teen parenting is related to higher rates of depression;13 diminished physical and mental health;1 reduced educational expectations, performance, and vocational success; increased welfare dependence; lower levels of participation in the workforce, and higher rates of poverty.14, 15
One of the recommendations for preventing early births to youth involved in the foster care system has been to extend state care to the age of 21 years.4, 12 The Fostering Connections to Success and Increasing Adoptions Act of 2008 made it possible for states to offer extended care to youth aging out of the foster care system. In Florida, extended care was adopted in 2014, allowing eligible youth to apply to extend their care until age 21 or 22 for those with a disability.24
The grandchildren of teen mothers are also more likely to experience numerous adverse outcomes, including maltreatment, infant mortality, behavioral problems, and educational failure.6 A significant concern is the intergenerational transmission of child maltreatment. Decades of research links teen parenting to an increased likelihood of involvement with CPS. A recent study using data from the Illinois Department of Family Services found that 39 percent of the children of foster youth had been the subject of substantiated reports of maltreatment, and 11 percent had been placed in care by the age of 5.16 In addition, children of teen parents are more likely to engage in risky sexual behaviors and become teen parents themselves.17
Teen parents in care and those aging out of care expressed the need for adequate housing, financial assistance, child care, and essential items such as cribs, clothes, and car seats.20, 25 The need for social support is also critical, as several studies report a lack of support from even one caring adult.20, 25 In a qualitative study involving interviews with teen parents and their service providers, Radey, et. al. (2016) found that young parents aging out of the foster system expressed a strong desire to be good parents but were very overwhelmed by the demands of parenting and providing for their own needs. Service providers noted what they perceived as a systemic failure in preparing adolescents for living independently. The authors conclude that interventions for this vulnerable population must address basic needs, social support, and developing effective parenting strategies.25
Disparities. While teen pregnancy rates across racial/ethnic groups are half of what they were ten years ago, disparities between groups continues. Hispanic and Black youth are twice as likely to give birth in their teens as White youth, and five times more likely than Asian and Pacific Islander youth.14, 15 These disparities are also evident across studies among pregnant and parenting youth in foster care.6, 11 An additional disparity identified across studies is that negative outcomes associated with early parenting disproportionately affect young women compared to young men. Teen mothers are less likely to graduate from high school than teen fathers, and are more likely to be unemployed and live in poverty.15, 18
Current Interventions and Best Practices There is a consensus across studies that knowledge regarding sexual health and contraception is critical for foster youth, who are likely to engage in sexually risky behavior at a younger age than their peers.19, 16, 20, 21, 22, 12 Many experts argue that pregnancy prevention efforts must target foster youth during the critical period between ages 17 and 19 years, as they are transitioning out of care.23, 15, 10, 23, 12 However, King and Wert (2017) stressed that social workers and health care professionals need to discuss sexual and reproductive health with youth in care between the ages of 13 and 16 years, before they become sexually active.
While there are relatively few evidence-based programs for teen parents in foster care, Finigan-Carr et al. (2015) reviewed twenty-two interventions for teen parents with the express purpose of providing child welfare workers with a list of evidencebased practices. Among the 22 interventions reviewed, seven provided the most robust evidence that they were effective in preventing repeat pregnancies and fostering parenting skills.21 The next section will highlight some of their findings with regards to intervention programs that appear to show the most potential for positive outcomes among youth in the foster care system. One of the most promising interventions, Families and Schools Together (FAST), a community-based, multifamily group intervention implemented in school settings, demonstrated significant increases in “parental self-efficacy, improved parent-child ‘bonds,’ reductions in stress and family conflict, and increases in social support” (p. 13).21 Although not explicitly used with foster youth, the curriculum’s demonstrated capacity for competent cultural adaptations with multiple racial/ethnic groups suggests its facility to be customized for youth in foster care. Of the remaining top seven interventions reviewed by FiniganCarr et al. (2015), three were home visiting programs that demonstrated reductions in the number of repeat pregnancies and improvements in positive parenting skills. Based on the author’s ratings, the most promising intervention for avoiding rapid repeat pregnancy and improving the parenting of infants was Computer Assisted Motivation Intervention (CAMI). This intervention uses risk summaries or algorithms that assess sexual risk behaviors and readiness to engage in pregnancy prevention to guide motivational interviewing by trained counselors.21 The authors note that additional research is needed to determine whether these interventions will have similar impacts when focused on youth in foster care. The Nurse-Family Partnership Program was rated as a “well-supported” program involving home visits by registered nurses to low-income mothers that begin during pregnancy and continue through the child’s second birthday (p. 7).21 One of the challenges the authors noted was that teen pregnancies among foster youth might not be identified early enough to have comparable results. Black’s Home Visiting Program, based on social cognitive theory, was rated as supported by research evidence, although based on a single study.21, 27 This program involved bi-weekly parenting home visits emphasizing “interpersonal negotiation skills, adolescent development, and parenting” (p.7).21 Results showed significant reductions in rapid repeat pregnancies and school dropout. One case management focused intervention called the Adolescent Parenting Program in North Carolina demonstrated that case management services provided by social workers and health service professionals help reduce rapid repeat births. However, the study design did not make it possible to assume causality.21
A recent qualitative study found that communicating with youth about sexual health was perceived as a significant challenge by caregivers.19 Caregivers who participated in the study’s focus group identified numerous barriers to effective communication, including developmental delays of teens in their care; their own lack of confidence in their knowledge regarding sexual health and contraception; and inability to bridge generational, sexual orientation, gender, and cultural differences.19 The authors recommend brief caregiver-oriented interventions to improve caregivers’ ability to approach communication about sexual health with youth who have histories of sexual trauma, developmental delays, or may simply be very different from themselves.19
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Although there are many programs targeting teen pregnancy prevention, the majority do not address the unique needs of youth in foster care. However, Making Proud Choices, initially designed for low socioeconomic, African-American youth in communities with a high prevalence of HIV, has shown promise as a potentially effective intervention for foster youth.26 Participating youth demonstrated significant improvement in their knowledge and attitudes regarding sexual health; however, long-term data regarding its efficacy in pregnancy prevention is not yet available.
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References
Summary In spite of national progress in the battle to curtail teen pregnancy, the number of births to youth in foster care and/or exiting foster care continues to be a source of concern. These young parents and their children face considerable challenges and experience many adverse outcomes. Current research supports the need not only for financial assistance, but for extensive social support and education in sexual health and parenting. Evidence-based interventions that have been successful in reducing pregnancy and birth rates in the general population must be tailored to meet the unique needs of this vulnerable population.
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Additional Resources
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10 Ways to Address Teen Pregnancy Prevention Among Youth in Foster Care | Power to Decide. (n.d.). Retrieved May 5, 2020, from https://powertodecide.org/what-we-do/information/resource-library/call-to-action Dworsky, A. (2011) Midwest evaluation of the adult functioning of former foster youth. Chapin Hall at the University of Chicago. Retrieved 5/14/20 from https://www.chapinhall.org/research/midwest-evaluation-of-the-adult-functioning-of-former-foster-youth
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Patel, P. & Sen, B. (2012). Teen motherhood and long-term health consequences. Maternal & Child Health Journal, 16(5), 1063–1071. https://doi.org/10.1007/s10995-011-0829-2 Martin, J. A., Hamilton, B. E., Osterman, M. J. K., Driscoll, A. K., & Drake, P. (2018). National Vital Statistics Reports. Births: Final Data for 2017 (Volume 67, 8; National Vital Statistic Reports, p. 50). National Center for Health Statistics.
Florida Department of Health. (n.d.). FLHealthCHARTS Data Viewer. Retrieved April 24, 2020, from http://www.flhealthcharts.com/charts/DataViewer/BirthViewer/BirthViewer.aspx?cid=0001 Dworsky, A. & Courtney, M. E. (2010). The risk of teenage pregnancy among transitioning foster youth: Implications for extending state care beyond age 18. Children & Youth Services Review, 32(10), 1351–1356. https://doi.org/10.1016/j.childyouth.2010.06.002 Courtney, M. E., Dworsky, A. L., Cusick, G. R., Havlicek, J., & Perez, A. (2007). Midwest evaluation of the adult functioning of former foster youth: Outcomes at age 21. Chapin Hall Centeroat the University of Chicago, 96. Putnam-Hornstein, E. & King, B. (2013). Cumulative teen birth rates among girls in foster care at age 17: An analysis of linked birth and child protection records from California. Child Abuse & Neglect, 38(4), 698–705. Kirby, D., & Lepore, G. (2007). 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C., & McMillen, J. C. (2013). Pregnancy risk among older youth transitioning out of foster care. Children and Youth Services Review, 35(10), 1760–1765. https://doi.org/10.1016/j.childyouth.2013.08.001 Boustani, M. M., Frazier, S. L., & Lesperance, N. (2017). Sexual health programming for vulnerable youth: Improving knowledge, attitudes, and behaviors. Children and Youth Services Review, 73, 375–383. https://doi.org/10.1016/j.childyouth.2017.01.013 Fostercarereviewuser. (n.d.). Independent living / Extended foster care. Foster Care Review. Retrieved May 17, 2020, from https://www.fostercarereview.org/our-work/independent-living-reviews/ Radey, M., Schelbe, L., McWey, L. M., Holtrop, K., & Canto, A. I. (2016). “It’s really overwhelming”: Parent and service provider perspectives of parents aging out of foster care. Children & Youth Services Review, 67, 1–10. https://doi.org/10.1016/j.childyouth.2016.05.013 Taylor, R. J., Shade, K., Lowry, S. J., & Ahrens, K. (2020). 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