impact of an increase in family planning services on the teenage population of Philadelphia, The

Family Planning Perspectives, Mar 1995 by Hughes, Mary Elizabeth, Furstenberg, Frank F Jr, Teitler, Julien O

Since teenage pregnancy and childbearing became public concerns in the United States in the early 1970s, public and private institutions have established countless interventions to help adolescents avoid pregnancy. Preventive interventions are attractive, for unlike programs aimed at teenage parents, they seek to reduce the incidence of teenage pregnancy, rather than merely ameliorate its often costly and sometimes intractable consequences. Motivated by the recognition that facilitating consistent contraceptive use is key to preventing teenage pregnancies, the provision of teenage-oriented family planning services has been a common preventive intervention.(1)

Based in part on the experience of other developed nations--where rates of pregnancies, abortions and births among teenagers are markedly lower, even when levels of teenage sexual activity are relatively high--it is widely believed that U. S. adolescents are capable of engaging in the responsible sexual decision-making that results in relatively few unplanned pregnancies and births.(2) Programs designed to achieve this end typically support teenagers' contraceptive use through education and counseling, in addition to providing supplies. While such services are increasingly provided by school linked health centers, community agencies remain an important source of teenage-directed contraceptive services.

Although community family planning services have proliferated over the past two decades, relatively little is known about their impact on teenage reproductive behaviors. Despite recent advances in evaluation research, clinic services remain underevaluated.(3) Understanding the impact of clinic services is critical, because rates of teenage childbearing have been persistently high. The growing risk that adolescents face of becoming infected with a sexually transmitted disease has in creased the urgency of designing reliable strategies to encourage protected intercourse among sexually active teenagers. Systematic evaluation research is important not only to demonstrate which types of programs will work, it is also key to clarifying which programs are most cost-effective in the face of limited resources.

Analyses of the population impact of contraceptive provision--its effects on the behavior of the entire population, not just among those who actually use clinic services--are particularly important. This concept is critical to evaluation research, since the overall policy goal is to bring down rates of pregnancy and childbearing among the teenage population, not just among the self-selected clients of family planning clinics. We emphasize the point because it is often obscured in the existing empirical literature; furthermore, it has important ramifications for study design. While patient-based analyses are useful for clarifying issues such as the effects of alternative service protocols, results based on client data cannot be used to draw conclusions about population-level issues, as they are contaminated by selectivity bias. To assess the population impact of a program, data representing the entire target population must be collected and analyzed.

Most existing evaluations of community family planning services are clinic-based.(4) The limited research on the population impact of such programs has produced conflicting evidence--a few analyses found that a greater density of services was related to lower rates of teenage pregnancy or childbearing;(5) several others found no relationship or a mixed relationship between the availability of services and fertility rates among adolescents;(6) and still others found the opposite relationship, in which greater availability was associated with higher rates.(7) Making sense of these discrepant findings is difficult, as the studies employed dissimilar designs, examined data for disparate time periods and utilized different dependent variables.

Further research is needed to determine the extent to which availability of services can be relied on as a strategy to reduce unplanned pregnancy and childbearing among teenagers. If the availability of teenage-specific family planning resources has a strong negative effect on community fertility rates, then the prospects of success for the relatively straightforward strategy of increasing availability are good. However, if availability is unrelated, or has only a weak negative relationship to teenage fertility, then the problem is clearly greater than the supply of services. Attention would then need to be shifted to more subtle population-based questions, such as patterns of selectivity in service use or the social context of teenage sexual experience. Finally, it is important to assess whether, as some critics have argued, availability unintentionally increases rates of teenage pregnancy and childbearing by condoning, if not encouraging, teenage sexual activity.(8)

The RESPECT Project

In this article, we assess the population impact of an expansion of teenage-directed family planning services in the Philadelphia area. The service-expansion project was funded by the William Penn Foundation with the expectation that increasing contraceptive services for sexually active teenagers would raise the proportion of the at-risk population served and lower fertility rates. The project, known by the acronym RESPECT (Responsible Education on Sexuality and Pregnancy for Every Community's Teens), was implemented by a consortium of nine health care agencies. Between January and August of 1988, nine existing clinics either increased services for teenagers or began serving teenagers for the first time, while three new clinics offering services to teenagers opened in communities where there had previously been no clinic. Each of the clinics expected to draw teenage clients from a well-defined geographic area surrounding the clinic.