Cause for Concern:
Unwanted Pregnancy and Childbirth Among Adolescents in Foster Care
By Jennifer Friedman
Teen pregnancy is a significant problem in American society.1 Pregnancy and parenting are associated with a host of negative consequences for teen parents, the children of teen parents, and society at large. Youth in foster care, an already vulnerable population, seem to experience the risks of teen pregnancy and parenting at a higher rate than their counterparts not in care. And foster youth report higher rates of unwanted pregnancy and childbirth. This suggests that youth in foster care may be experiencing barriers to reproductive health and pregnancy prevention care and education. The National Center for Youth Law (NCYL) has initiated a project to examine the problem of unwanted pregnancy among foster youth. In the coming months, NCYL and Youth Law News will present more information about the issue and recommend actions readers can take to address the issue. This article begins the series by outlining the scope of the problem and discussing some of the factors that may lead to higher unwanted pregnancy rates among foster youth.
Why Worry about Teen Pregnancy?
Teen mothers “tend to exhibit poorer psychological functioning, lower levels of educational attainment, more single parenthood, and less stable employment than do those with similar backgrounds who postpone childbirth.”2 The children of teen mothers are more likely to drop out of high school, be incarcerated at some time during adolescence, give birth as teenagers, face unemployment as young adults and, at some point, end up in the foster care system.3 In 2008, teen childbearing cost the U.S. public almost $11 billion per year; most of these costs resulted from the negative consequences that often follow teen pregnancy, such as increased costs for health care, foster care and incarceration, as well as lost tax revenue resulting from the lower rates of employment of teen parents.4
Research shows that adolescents in foster care engage in sexual activity at an earlier age, have higher rates of pregnancy (intended and unintended) and have higher birth rates (wanted and unwanted) than youth of the same age not in state care. In 2006, the Midwest Evaluation of the Adult Functioning of Former Foster Youth (the “Midwest Evaluation”), published a study offering an in-depth picture of the reproductive health of youth in foster care. The researchers followed a sample of 767 foster care youth in Illinois, Iowa and Wisconsin from the ages of 17 or 18 to 26.5
At the start of the study, the Midwest Evaluation found that young women in foster care were more likely to have engaged in sexual activity than their same-aged peers and less likely to have used birth control during the previous year.6 Approximately one-third of the young women in foster care reported a history of pregnancy, compared with 19 percent of their same-aged peers.7
Two years later, the number of pregnant foster youth increased, as did the gap in pregnancy rates between those in foster care and the general population. At age 19, 48 percent of the girls in foster care had been pregnant, compared with 20 percent of girls nationwide.8 Among the group of the girls in foster care who had been pregnant by age 19, 46 percent of those girls became pregnant more than once, compared with 29 percent of their peers not in foster care.9
The risk of early pregnancy remained with these young women even after they transitioned out of foster care. By age 21, 71 percent of the young women who had been in foster care had been pregnant, compared with 34 percent of their peers nationwide.10 The higher rate of pregnancy among young women newly aged out of foster care has been documented by other studies as well. A 2002 UC Berkeley study of California youth found that approximately two-thirds of the women who aged out of the child welfare system between 1996 and 1998 gave birth within five years.11 A study of former foster care youth in Utah reached a similar conclusion. The study found that 31 percent of female former foster youth ages 18 to 24 who aged out of the child welfare system gave birth within three years, at a rate 2.74 times higher than the general population.12
Young men in foster care, like their female counterparts, are also more likely to become parents early. Of the adolescent males included in the Midwest Evaluation, half of the boys had gotten a partner pregnant, compared with only 19 percent of their peers not in foster care.13 Though limited in geographic scope, the Midwest Evaluation is generally credited with documenting for the first time the earlier start to sexual activity and the higher rates of teen pregnancy among youth in foster care.14
Unwanted Pregnancy and Childbirth in Foster Youth
At the outset, it is essential to note that some young women in foster care may want to get pregnant. Studies have observed among some foster youth a “desire . . . to have a baby as a teen,”15 as some teens perceive having a baby as a way to create a new family, to provide a sense of stability, and to prove themselves to be better parents than their birth parents.16 In addition, studies suggest that foster youth experience a greater acceptance of early pregnancy by their families of origin and their peers.17 The desire to start a new life, coupled with a greater social acceptance of early parenting, may lead some youth in care toward pregnancy and parenting earlier than their counterparts not in care. Certainly, this theory represents an opportunity for further study and, quite possibly, future advocacy or educational efforts.
However, data show that unwanted pregnancies outnumber wanted pregnancies among foster youth and unwanted births far outnumber wanted births. The Midwest Evaluation revealed that more than two-thirds of the foster youth who had been pregnant described their pregnancies as “unwanted,” compared with just over half of their pregnant peers.18 Foster and former foster youth also report significantly more unintended births than their peers.19 It is quite notable that so many more foster youth than their counterparts not in care describe their pregnancies and childbirths as unwanted. This suggests that youth in foster care may be experiencing barriers to reproductive health and pregnancy prevention care and education that youth not in care do not face.
Factors Leading to Unwanted Pregnancy and Birth Among Youth in Foster Care
This section introduces just some of the many complicated factors at play that may be responsible for the higher numbers of unwanted pregnancies and births among young women in foster care. Later articles in this series will delve in more detail into some of the issues identified in this section and propose action.
A. Reproductive Coercion
Relationship abuse among teens in foster care may contribute to the higher unwanted pregnancy and birth rates among foster youth. Relationship abuse among adolescents, like intimate partner violence among adults, involves a pattern of abusive and controlling behavior towards someone the abuser is dating or seeking to date. Teens and young women are especially vulnerable to this type of violence: women age 16 to 24 experience the highest rates of rape and sexual assault.20
Reproductive coercion is one type of behavior that a partner might use to maintain control in an abusive relationship.21 Examples of reproductive coercion include birth control sabotage, such as hiding a partner’s birth control pills, intentionally breaking a condom, or not withdrawing when that was the agreed-upon method of birth control. Reproductive coercion can also take the form of overt pregnancy pressure or coercion.22 This abuse can contribute to higher rates of unwanted pregnancy.
Research suggests that reproductive coercion is an acute problem for adolescents experiencing relationship abuse. For example, a 2005 study of 474 teen mothers on public assistance found that of those teens experiencing dating violence, 66 percent experienced birth control sabotage by a partner.23 Emerging evidence suggest that foster youth suffer intimate partner violence and reproductive coercion at higher rates than other young women.24
B. Instability in the Foster Care Setting
Youth in foster care frequently experience changes in their placement, which leads to uncertainty and instability. According to government estimates for 2011, 47 percent of youth in foster care were placed in a non-relative foster family home.25 The median length of stay in care was 13.2 months.26 On average, children in foster care experience 3.1 placement changes during their stay in care.27
This instability leads to inconsistent medical care and disrupted education, among other problems. Placement changes for youth in care are often accompanied by changes in physicians. As a result, many foster youth experience gaps in medical care. In the context of reproductive health care, such gaps are quite significant because birth control and sexual disease prevention needs are immediate and time-sensitive.
Changes in placement also often require foster youth to change schools. These changes raise the risks of a host of negative consequences, as frequent school transitions have been linked to low educational achievement and engagement and higher rates of school dropout.28 Moreover, higher educational performance has been linked with a reduced risk of teen pregnancy.29
In addition, for many teens in foster care, missing school might mean missing the only formal sexual education they might otherwise get. These teens risk “falling behind not only in academic subjects, but also missing the sex education sometimes delivered in traditional schools.”30
C. Diffusion of Responsibility
There are many adults involved in the life of a foster child, including the foster parent(s), judges, social workers, county staff, and in some instances, parents or other family members. None of these individuals, however, is specifically charged with the foster child’s sexual education. In a 2009 study of three California counties, case workers from the Department of Children and Family Services and staff from independent living programs were asked a multiple choice question: “Who usually provides pregnant foster youth with counseling on pregnancy options?”31 Available responses included “I do,” “foster parent or other caregiver,” “someone else,” or “no one I know of.” Across all three counties, “someone else” was the most common response.32 In the absence of a specific obligation toward reproductive health care, many adults involved in the life of foster youth might ignore these needs on the assumption that someone else will assume responsibility.
D. Lack of Policies and Training
There appears to be a lack of clear policies guiding access to reproductive health care for foster children. In a 1996 study, the Child Welfare League of America (CWLA) found that only ten states had written policies to address the provision of sexuality education and/or family planning services for youth in foster care.33 Recent research suggests that the gap remains. In surveys of foster parents, social workers, case workers and former foster youth in three California counties, a study by the Public Health Institute (PHI) found evidence that the roles of county staff are not clearly outlined in formal policies or procedures.34 Respondents cited a lack of clarity on “official” policy as a significant barrier to promoting sex education and reproductive health among foster youth.35 Similarly, in another study, 59 percent of child welfare staff members said their program lacked a specific plan for teen pregnancy prevention.36
Given the lack of policies, it is not surprising that there also a lack of training for service providers regarding sexual education and the provision of reproductive health care services to adolescents in foster care. The National Campaign to Prevent Teen Pregnancy has found that 58 percent of service providers working with foster youth said that they had not received sufficient training to work with teens or caregivers on preventing teenage pregnancy.37 The problem extends even to staff working in programs for pregnant and parenting youth: 43 percent of those staff members stated that they had not received adequate training to work with teens on pregnancy prevention.38 The focus in such programs tends to be on parenting, rather than on preventing future pregnancies.
Similarly, evidence suggests that foster parents are insufficiently trained on the subject of youth’s sexual education and reproductive health care needs. The Child Welfare League of America found that only 11 states reported training foster parents in sexuality education and none of the states mandated that foster parents receive such training.39
The lack of training and the lack of clear policies may create a void in which some staff members use their own religious or moral beliefs to guide foster youth needing help. Consider the comments of an anonymous staff member in one California county:
I was just pulling things from out of the air because I really didn’t know what was available to her. And then she asked if I knew anything about getting an abortion—and my personal opinion is just my personal opinion, but it really impacted what I said to her, because of course I didn’t want her to have an abortion.40
E. Confusion about Legal Consent and Confidentiality Rights
Confusion about who may provide legal consent for reproductive health care services might also undermine the ability of adolescents in foster care to access such services. Foster parents, county staff, and even foster youth themselves may have mistaken ideas about who may consent for sexual health care for adolescents in foster care, often to the detriment of youth seeking health care. If a youth is confused about who may provide or withhold consent, she may be less inclined to seek reproductive health care.
Concerns about privacy can also be a significant barrier to accessing care. Adolescents generally prefer not to have to share private information, particularly related to sex, and might avoid getting help if it means sharing private information. “A guarantee of confidentiality can be the deciding factor in whether [adolescents] seek necessary health care services.”41 Adolescents in focus groups have reported feeling intimidated or embarrassed about asking for birth control and have cited these concerns as a barrier to accessing contraceptives.42 Confidential reproductive health care is available to teens in every state but can be more difficult to access for youth in foster care for a variety of reasons that will be discussed in more depth in follow up articles.
F. Pregnancy History
There is evidence to suggest that pregnancy itself can be a barrier to adolescents receiving information about avoiding subsequent pregnancies. The PHI study concluded that pregnant youth in foster care do not consistently receive information about how to prevent addtional pregnancies. Group homes for pregnant youth often offer pregnancy and prenatal services, but do not provide information about future pregnancy prevention. As discussed above, there is often a lack of specific training for staff working with pregnant and parenting teens. The National Campaign’s survey of service providers found that 37 percent of staff in programs designed for pregnant and parenting foster teens reported that their program lacked a specific plan to help teens avoid future pregnancies.43
The lack of clear policies is frequently compounded by a lack of concern for pregnancy prevention education and support in the face of other, immediate needs. As one county staff member explained in the PHI study, the group homes for pregnant foster teens “don’t have the resources [to educate about future pregnancy prevention], they think the kids will smarten up and don’t do this again.”44 Or, in the words of a foster mother interviewed in the study, “[t]he first baby should teach them a lesson not to have more children, but it does not always work out that way.”45 Other respondents noted a “lack of interest” in discussing future pregnancy prevention in the face of “immediate needs” related to the current pregnancy.46
Adolescents in foster care, an already vulnerable population, face a heightened risk of teen pregnancy and early parenting. Preliminary research has turned up a complex web of factors that affect foster youth’s pursuit of reproductive health care services. Future articles in this series will present the legal framework for foster youths’ right to access reproductive health care, will consider in greater details some of the barriers to care, and will propose action readers can take to help reduce unwanted pregnancy and childbirth among teens in foster care.
Jennifer Friedman is an attorney working with Rebecca Gudeman at the National Center for Youth Law.
1See e.g., By the Numbers: The Public Cost of Teen Childbearing (The National Campaign to Prevent Teen Pregnancy, Washington D.C.) 2006 at 1 (describing early pregnancy and childbearing among teens as “pressing concern” in the United States and identifying nation’s teen pregnancy and birth rates as the highest in the industrialized world.)
2Petra Jerman, Norman Constantine & Carmen Nevarez, No Time for Complacency, Teen Births in California (2012); see also Centers for Disease Control and Prevention, About Teen Pregnancy (Public Health Inst., Center for Research on Adolescent Health and Development, Oakland) March 2012, at 3.
3See Unique Needs of Children Born to Teen Parents, Fast Facts (Healthy Teen Network, Washington, D.C.); see also Improving Outcomes for Older Youth in Foster Care (Casey Family Foundation, Seattle, WA) 2008, at 4 (describing “tragic cycle of involvement in the foster care system” among children born to young mothers who had been in the foster care system).
4See Saul Hoffman, By the Numbers: The Public Costs of Teen Childbearing (The National Campaign to Prevent Teen Pregnancy, Washington D.C.) 2006 at 1.
5See Mark Courtney et. al, Midwest Evaluation of the Adult Functioning of Former Foster Youth: Outcomes at Age 21 (Chapin Hall Center for Children, University of Chicago) December 2007, at 5-8.
6See Mark Courtney et al., Midwest Evaluation of the Adult Functioning of Former Foster Youth: Conditions of Youth Preparing to Leave State Care (Chapin Hall Center for Children, University of Chicago) February 2004, at 48.
7See id., at 37-38.
8See Mark Courtney et al., The Risk of Teenage Pregnancy Among Transitioning Foster Care Youth: Outcomes at Age 19 (Chapin Hall Center for Children, University of Chicago) May 2005, at 54 (surveying foster youth and comparing results to a nationally representative sample of same-aged peers).
9See Amy Dworsky & Mark Courtney, The Risk of Teenage Pregnancy Among Transitioning Foster Youth: Implications for Extending State Care Beyond Age 18, 32 Children and Youth Services Review 2010, at 1; see also Science Says: Foster Care Youth (The National Campaign to Prevent Teen Pregnancy, Washington, D.C.) August 2006, at 1 (reviewing Midwest Evaluation study).
10See Mark Courtney et. al, supra n.9, at 50.
11See Barbara Needell et al., Youth Emancipating from Foster Care in California (U.C. Berkeley Center for Social Services Research, Berkeley, California) May 2002, at 35.
12See Assessing Outcomes of Youth Transitioning from Foster Care (State of Utah, Department of Human Services) 2006, at 6-7.
13Id. at 52.
14A recent study by National Survey of Child and Adolescent Well-Being offers a snapshot of the incidence of teen pregnancy among foster youth nationwide that lends support to the conclusions of the Midwest Evaluation. The July 2012 NSCAW Wave 2 study surveyed 5,872 children in foster care and found that sexual activity was much higher than among the general population, and that pregnancy was also more common than among the general population. See NSCAW Wave 2 Report Child Well Being (U.S. Dept. of Health & Human Servs., Washington D.C.) July 15, 2012, at 13-13. The study found that 14.4 percent of girls aged 15 to 17 reported having ever been pregnant. Id. at 13, 52.
15See Louis Thiessen Love et al., Fostering Hope: Preventing Teen Pregnancy Among Youth in Foster Care (The National Campaign to Prevent Teen Pregnancy, Washington, D.C.) 2005, at 22.
16See id. at 13.
17Id. at 12.
18Id. at 38.
19See Fast Facts: Reproductive Health Outcomes Among Youth Who Ever Lived in Foster Care (The National Campaign to Prevent Teen and Unplanned Pregnancy, Washington D.C.) July 2009, fig 4.
20Futures Without Violence, The Facts on Adolescent Pregnancy, Reproductive Risk and Exposure to Dating and Family Violence (San Francisco) 2010, at 1.
21Linda Chamberlain and Rebecca Levenson, An Integrated Response to Intimate Partner Violence and Reproductive Coercion, (Family Violence Prevention Fund, San Francisco) 2010, at 5.
22Elizabeth Miller et al., Pregnancy Coercion, Intimate Partner Violence, and Unintended Pregnancy, Contraception (April 2010), p. 316.
23See Futures Without Violence, The Facts on Adolescent Pregnancy, supra n.19 at 1; see also Committee Opinion, Reproductive and Sexual Coercion (The American Congress of Obstetricians and Gynecologists, Washington D.C.) 2013, at 2.
24Id.; see also Melissa Jonson-Reid, et al., Dating Violence Among Emancipating Foster Youth (Washington University, St. Louis, MO) 2007, at 569-70 (noting higher prevalence of dating violence among foster youth and calling for additional research).
25Adoption and Foster Care Analysis and Reporting System (AFCARS), (U.S. Dep’t. of Health & Human Services, Washington, D.C.) July 2012, at 1.
26Id. at 3.
27Foster Care by the Numbers, Casey Family Programs (Sept. 2011), at 1.
28Jennifer Manlove et al., Teen Parents in Foster Care: Risk Factors and Outcomes for Teens and Their Children, (Child Trends, Washington D.C.) 2011, at 3.
30Wendy Constantine et al., Sex Education and Reproductive Health Needs of Foster & Transitioning Youth in Three California Counties (PHI, Oakland, CA) 2009, at 4.
31Id. at 17.
33See Sexuality Education for Youths in Care: a State-by-State Survey, Child Welfare League of America Press (CWLA Washington D.C.) 1996, at 9.
34See PHI Study, supra n.31 at 21.
35Id. at 21.
36See Fostering Hope, supra n.16 at 19.
37See Fostering Hope, supra n.16 at 20; see also PHI Study, supra n.31 at 30 (citing need for more training regarding adolescent sexuality, prevention, resources and engaging youth).
39See CWLA Survey, supra n.34 at 12.
40PHI Study, supra n.31 at 23.
41Harriet B. Fox and Stephanie J. Limb, State Policies Affecting the Assurance of Confidential Care for Adolescents, Fact Sheet #5 (National Alliance to Advance Adolescent Health, Washington, D.C.) April 2008, at 1.
42See Fostering Hope, supra n.16 at 16.
43See Fostering Hope, supra n.16 at 19.
46Id. at 19.