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Options Counseling for Pregnant TeenagersThis month's educator skill is an overview of how educators, counselors, and health care providers can help young women make informed decisions about their options once they know they are pregnant. This is NOT a substitute for formal training in options counseling. Instead, it reviews key points and issues to help professionals who interact with sexually active teenagers provide immediate support and, if needed, additional referrals. This educator skill begins with an introduction, which is followed by the goals of pregnancy options counseling, a brief review of the counselor's role, and information and counseling points that address each of three options a pregnant teenager faces: A list of Resources is included at the end. See this month's Learning Activity for a decision-making model that will help a counselor and a pregnant teen consider all the options — and the next steps.
In the United States, four of every ten young women become pregnant at least once before they turn 20, leading to approximately one million teen pregnancies a year.1 About half of all pregnancies are unintended, but among teenagers, the proportion is higher — 80 percent. Not surprisingly, about 79 percent of teen pregnancies occur among unmarried teens.2 Many complicated reasons converge to contribute to these rates of teen pregnancy. For some young couples, lack of basic knowledge leads to pregnancy. In others, the knowledge may be there, but myths and wishful thinking prevail: "It can't happen to me ..." "It can't happen the first time ..." "It can't happen if we're standing up." Even those teens who have knowledge about how to protect themselves and the best intentions to do so may not have access to contraception, or may not use it correctly every time. Even when they use contraceptives properly, they may experience the failure rates that are built in, to some degree, to every form of protection except abstinence. And for a tragic minority, none of these reasons apply, for they are victims of rape or incest. Finally, even though 80 percent of teen pregnancies are unintended, at least 20 percent are wanted in some way — because of a desire to be a mother and a grown-up, pressure from a partner, or simply a quest for love from an adoring baby.
Studies that compared adolescents who raised their children, placed the children for adoption, or had an abortion found similar levels of satisfaction. Teens in these studies generally believed they made the right choices.3,4 "Central to this expressed satisfaction," notes Michael Resnick, who reviewed the studies, "was a sense of ownership over the pregnancy decision, and the belief that the outcome was not forced on the adolescent but arrived at through a careful process of evaluation and decision-making."5 That's exactly what options counseling aims for: a careful process of evaluation and decision-making, after which the teenager feels that she made the right choice for her particular circumstances. By definition, this means that the same choice will not work for every teenager. The task for the pregnant teenager — and the counselor or educator trying to help her — is to discover what the right choice is for her particular situation. Specifically, effective pregnancy options counseling should:
To give a pregnant teenager a true sense of the options, counselors must provide information about each option. However, they must remain neutral and non-directive, letting the teenager reach a decision that is right for her. This is a difficult challenge for anyone trying to help a pregnant teenager. We may have strong opinions about what life holds in store for her and her baby, or negative views about adoption or abortion. But our opinions as counselors and educators do not deserve center stage in this situation. The teen's opinions – informed, supported, and thought through with our help – do. For most teenagers who find out they are pregnant, the situation is a crisis with serious implications for their current relationships, their immediate futures, and their overall lives. These adolescents need caring, compassion, and options, not judgments. In your counseling role, if you do not feel you can provide unbiased information to a teen in this situation, the fair thing to do is to refer her to someone who can. The counseling part of options counseling means using techniques such as open-ended questions and reflective listening to help the pregnant teenager understand her feelings and explore what she can do about her situation. Remind her that she has three choices:
Emphasize that there is no right or wrong choice that applies to everyone. Only she can decide which choice is right for her, but it is not an easy decision. Your job is to help her think it through. General questions to consider are:
If the teenager expresses an intention to continue with the pregnancy and parent the child herself, the discussion can cover her reasons for wanting to do so, as well as some of the outcomes — both positive and negative — if she does so. These questions can help:
As recently as 50 years ago, 95% of unmarried and pregnant teenagers who gave birth placed their babies for adoption. Today, the figure is less than 5%.7 What led to this reversal? In part, some of the stigma of single parenting has faded, and young pregnant women have more options. Some researchers believe that adoption is viewed so negatively by society at large — and by health and social service professionals in particular — that it is rarely presented as a viable option to pregnant teenagers. Some studies of the decisions made by pregnant teenagers also indicate that teenagers themselves shy away from adoption. One of the signals of how adoption is viewed is the language used to describe it. Over the years, adoption has acquired a vocabulary that subtly (and sometimes not-so-subtly) reinforces the idea that adoption is an unnatural, desperate, and substandard family experience for everyone involved. To counter this, the Positive Adoption Language (PAL) movement has suggested terms that do a better job of respecting the birth parents, adoptive parents, and adoptees. Here are some highlights to consider:
In discussing adoption options with a pregnant teenager, use the more neutral terms suggested by PAL. Types of Adoption In the past, almost all adoptions were what is now called "closed" adoption. In a closed adoption, the records about the birth parents are sealed — sometimes forever, and sometimes until a child is a certain age or seeks information through court actions to unseal records. In a time when pregnancy outside of marriage was judged much more harshly than it is today, closed adoptions were deemed the best recourse for the birth parents, the child, and his or her adopted family. Today, a growing movement has emerged that is known as "open" adoption. In open adoption, the birth parents and adopted parents have a relationship that they establish. The birth parents choose the family that will raise their child. Both sets of parents meet and talk, agreeing to some type of ongoing contact. Existing research suggests that children accept these relationships. One of the reasons may be that their curiosity about their birth parents is satisfied early on in their development. Adoptions can be arranged in several different ways: through a private adoption agency, by individual county adoption services, by non-profit adoption agencies, or independently (by attorneys, doctors or nurses, or clergy). Birth mothers and fathers have certain legal rights that differ depending on the type of adoption. Fathers must give permission for adoption; if the father is not available, his parental rights may be terminated, but only after a court hearing. The birth mother must tell the court, agency, or attorney who the child's father is, but she need not tell anyone else (including her parents, her doctor, or the adoptive parents). In private adoptions (e.g., through an attorney, doctor, or member of the clergy), a birth mother may change her mind up to six months after signing adoption papers, or until the adoption is finalized in court. In an agency adoption, the period is much shorter – after the birth mother and father have signed papers and they have been filed with the state (typically, within a week). If a pregnant teenager is interested in adoption, refer her to a local adoption resource that meets the needs she has identified. Foster and Kinship Care Foster care places children who cannot be with their birth parents in another home and family. In some cases, the situation is permanent or at least open-ended because the birth parents have harmed or neglected their children. In other cases, foster care provides a temporary solution. At some point in the future, the birth and foster parents plan on reuniting the children with their birth parents. Kinship care is a variant of foster care in which a relative — a grandparent, aunt, uncle, or other adult — cares for children whose birth parents are temporarily unable to do so. While these arrangements are often informal, they can be put in place more formally through a state's foster care agency. In some cases, these may be viable solutions worth exploring for pregnant teens.
An abortion is a procedure in which a developing fetus is removed or expelled from the woman's uterus. Almost 90% of the 1.3 million abortions that take place annually in the United States occur during the first 12 weeks of a pregnancy. Access to Abortion Services Abortion has been legal in the United States since 1973, when two landmark Supreme Court cases — Dow v. Bolton and Roe v. Wade — were decided. The two Supreme Court decisions state that the decision to have a first-trimester abortion (within the first 14 weeks of a pregnancy) must be left to a woman and her physician. In the second trimester (15-24 weeks), the state can regulate abortion procedures to protect a woman's health. In the third trimester, the state may regulate or restrict abortion, except when necessary for the mother's health. Because the trimester distinction is important in terms of the availability of abortion services and the type of procedure used, an important first step in counseling a pregnant teenager who is considering an abortion is to find out the date of her last menstrual period. In the United States, opposition to abortion has made it more difficult for women to obtain abortions. In 1996, 85% of U.S. counties had no abortion provider — a proportion that has increased steadily since the late 1970s. (In rural areas, the figure was 94% of counties.) In 17 states, a mandatory delay or state-directed counseling is required. In 32 states, pregnant women under the age of 18 must obtain parental consent or must notify their parents.8 In states where parental involvement is required, young women have the option of seeking a court order exempting them from notifying their parents, if they can demonstrate to the court that they are mature enough to make an informed decision and that the abortion is in their best interest. Most abortions are provided in abortion clinics — clinics where at least half the patient visits are for abortions. During the first trimester, the cost of an abortion typically ranges from $300 to $500. (The cost is higher for abortions in the second trimester.) Eighteen states cover the cost of abortions for Medicaid-eligible women, but the federal Medicaid program pays for abortions only in cases of life endangerment, rape, and incest. If you or your colleagues are counseling young pregnant women about this topic, be sure you know where abortions are available in your area and whether or not your state covers any of the costs through Medicaid. Abortion Methods Surgical
Methods A less common method is called dilation and curettage (D&C). In a D&C, a curette replaces the vacuum and is used to remove any developing tissue from the uterus. It is less commonly used because it requires a larger dilation of the cervix and is associated with more pain and bleeding. When done in a doctor's office, a first-trimester abortion is considered an extremely safe medical procedure. Possible complications include infection, cervical or uterine trauma, or excessive bleeding. D&Cs are associated with slightly higher risk of uterine or cervical damage than vacuum aspirations. In second-trimester abortions, the cervix is gradually dilated and a dilation and evacuation (D&E) is performed. A D&E is a combination of the vacuum aspiration and D&C methods described above. Typically, this technique is used between 13 and 16 weeks of gestation. The risks of complications from second-trimester abortions are similar to those for first-trimester abortions, but there is an increased risk of severe complications. Because of the possibility of complications, it is important that patients undergoing an abortion understand possible warning signs of potential problems, such as fever, chills, aches, pain, cramping, tenderness, discharge, or bleeding. Medical Abortions These drug combinations have advantages and disadvantages compared to surgical abortions. Women who have had medical abortions report that these methods can feel more "natural" than invasive surgery — more like a heavy period, for many women. For others, the bleeding, cramping, and nausea caused by the drugs are more severe. Although surgical abortions are very safe, they do pose a small risk of perforating the uterus or causing infection; medical abortions avoid these particular risks. However, medical abortions have other potential disadvantages. They are 95% effective within the first seven weeks of pregnancy, but are less certain than surgical abortions — especially later in the first trimester. Women who choose a medical abortion must visit their physician several times and may have to wait several weeks before they know whether the drugs have worked.10 A woman contemplating an abortion should know about both surgical and medical options so that she can weigh their advantages and disadvantages herself and make an informed choice. Pre-Abortion Counseling If a teenager wants to end her pregnancy and has rejected the other options — raising the child herself or placing the child in adoption or foster care — it is appropriate to discuss the types of options available to her to end her pregnancy. As noted above, a key factor will be the current length of her pregnancy, as determined by her last menstrual period. Making the decision to have an abortion is never an easy one. For young women in particular, a number of factors may make the decision even harder. Money and lack of access to health care can play a role. Some young women are in denial, trying to convince themselves that they are not really pregnant. Others may not know the signs of pregnancy, or may not feel many symptoms. Fear — of the reactions of parents, boyfriends, and other relatives — is another common factor. State laws requiring parental consent (or judicial exemption) may add pressure. Some may have religious beliefs that are against abortion — or be part of families where those beliefs are strong. Because of these factors, it is especially important to explore the pregnant teenager's support system and to confirm that she herself wants to end the pregnancy (i.e., that she is not doing so under pressure or coercion). After a pre-abortion counseling session, she should understand the types of procedures available to her and how she can access them. She should know what to expect before, during, and after the procedure. Post-Abortion Counseling Topics to be covered in a post-abortion counseling session include:
See this month's Learning Activity for a decision-making model and worksheet to help teenagers who are struggling with the decision about how to handle an unplanned pregnancy.
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