Skills for Educators
Options Counseling for Pregnant TeenagersThis 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:
- continuing the pregnancy and raising the child herself,
- continuing the pregnancy and placing the child for adoption, and
- terminating the pregnancy.
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.
IntroductionIn 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.
The Goals of Pregnancy Option CounselingStudies 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:
- Reduce anxiety so that the pregnant teenager can concentrate on the decisions she has to make
- Create a safe environment in which she can discuss her hopes and fears about her decision
- Impart knowledge and facts about the various options and their implications
- Identify the teenager's strengths and support systems
- Clarify her choices and her feelings about her choices
- Help her make the decision that is right for her
- Help her accept responsibility for her decision
- Help her act on her decision, with referrals as needed, and
- Support her decision
The Counselor's RoleTo 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:
- She can have the baby and raise the child herself
- She can have the baby and place it for adoption or foster care
- She can end the pregnancy.
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:
- Which choices could I live with?
- Which choices are impossible for me?
- How would each choice affect my everyday life?
- What would each choice mean to the people closest to me?
- What is going on in my life now?
- What are my plans for the future?
- What are my spiritual and moral beliefs?
- What do I believe is best for me in the long run?
- How would my choice affect me financially?6
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:
Continuing with the Pregnancy and Parenting the Child
- Why does she want to continue the pregnancy? (Teenagers who make this choice may have vastly different reasons for doing so, with different implications for their next steps. For example, they may feel pressure from family members or the baby's father. They may be afraid of pursuing other options. They may have longed for a baby.)
- How do significant others in her life — parents, partner — feel about it? (Or, if they don't know yet, how will they feel?)
- What are her plans for prenatal care during her pregnancy? Does she have access to insurance and a health care provider, or will she need referrals? Does she need help from you to obtain these services, or is there someone else she can turn to?
- What are the immediate tasks and challenges for the next few days (e.g., telling her partner, parents, or others)?
- How will the pregnancy and parenthood affect her education? (Will she be able to continue to attend school in the same school, or transfer to an alternative school or program for pregnant teenagers?)
- Where will she live during the pregnancy? Will she be able to live at home during the pregnancy, or does she plan to live with her partner or on her own, or at a shelter?
- Where will she live after the pregnancy?
- What will her partner's role be in helping to support her and the baby — financially and with child care and other support?
- How will the baby affect her plans for the future and her partner's plans?
- Who will take care of the baby while she works or completes her education?
- What are other options that she is considering? What are their pros and cons?
- How do these other options compare with the option of continuing the pregnancy and parenting the child?
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.
Placing the Baby for 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:
Preferred PAL Terms
|Real parent, natural parent (implies that adoptive relationships are artificial or that blood relationships are the most important relationships)
||Birth parent, birth mother, birth father (describing the man and woman who conceived and gave birth to a child)
Parent, mother/mom, father/dad (describing the people who raise and nurture a child)
|Surrendered, released, relinquished, gave up, put up … the baby for adoption
||Placed the baby, chose adoption, made an adoption plan
|Kept the baby
||Chose to parent/raise the baby
In discussing adoption options with a pregnant teenager, use the more neutral terms suggested by PAL.
Types of AdoptionIn 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 CareFoster 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.
Terminating the Pregnancy
Access to Abortion ServicesAbortion 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.
During the first trimester, the most common method used is vacuum aspiration. In a vacuum aspiration, the cervix is dilated (usually with local anesthesia), and a vacuum curette is introduced into the uterine cavity. Any products of conception are removed from the uterus. This procedure can be done in an office throughout the first trimester (and up to 16 weeks after gestation).
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, as opposed to the surgical ones described above, use combinations of drugs to cause an abortion. Two methods, both used early in pregnancy (within the first nine weeks or sooner), include combining Misoprostol (a prostaglandin) with either Mifepristone (RU-486) or Methotrexate (a drug used to treat ectopic pregnancies, among other things).9
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 CounselingIf 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 CounselingTopics to be covered in a post-abortion counseling session include:
- symptoms that may be signs of a post-abortion complication (such as infection or hemorrhage)
- future contraceptive plans to avoid another unplanned pregnancy
- assessment of the teenager's emotional state and support system
- referrals to any needed services
- scheduling a post-abortion check-up.
The American College of Obstetricians and Gynecologists (ACOG) offers a variety of patient education brochures that explain pregnancy, prenatal care, childbirth, and postpartum care. Order them from ACOG's web site (www.acog.org) or resource center (202-863-2518).
The Child Welfare League of America (CWLA) (www.cwla.org) offers manuals for both parents and counselors on managing the grief and loss that can arise with adoptions. The CWLA web site has links to open adoption publications and sites.
The National Council for Adoption (www.ncfa-usa.org) includes information on how to choose an agency or attorney as well as an annual adoption factbook.
The Planned Parenthood National Hotline (1-800-230-PLAN or www.plannedparenthood.org) can connect teenagers to a nearby Planned Parenthood clinic that can offer options counseling and adoption referrals.
The National Resource Center for Foster Care and Permanency Planning is housed at the Hunter College School of Social Work on behalf of the Department of Health and Human Services (DHHS), Administration on Children and Families (ACF). Their web site (www.hunter.cuny.edu/socwork/nrcfcpp) provides links to many resources on foster and kinship care.
For abortion referrals, contact the Planned Parenthood National Hotline (1-800-230-PLAN or www.plannedparenthood.org) or the National Abortion Federation Hotline (1-800-772-9100).
See the Learning Activity Making Difficult Decisions for a decision-making model and worksheet to help teenagers who are struggling with the decision about how to handle an unplanned pregnancy.
|1 National Campaign to Prevent Teen Pregnancy. http://teenpregnancy.org
|3 Kalmuss, D., Namerow, P.B., and Cushman, L.F. Adoption versus parenting among young pregnant women. Family Planning Perspective. 1991. 23(1):17-23.
|4 Resnick, M.D., Blum, R.W., Bose, J., Smith, M., and Toogood, R. Characteristics of unmarried adolescent mothers: Determinants of child rearing versus adoption. American Journal of Orthopsychiatry. 1990. 60(4):577-584.
|5 Resnick, M.D. Adolescent pregnancy options. Journal of School Health. 1992. 62(7):298-303.
|6 Adapted from Planned Parenthood of Connecticut, Inc.
|7 Resnick, op. Cit.
|8 Henshaw, S.K., Tew, S., and Keating, A. An overview of abortion in the United States. Slides and data prepared by Physicians for Reproductive Choice and Health (PRCH) and the Alan Guttmacher Institute (AGI). 2002.
|9 Cates, W.C. And Ellertson, C. Abortion. In: Hatcher, R.A., et al. Contraceptive Technology. New York: Ardent Media, Inc. 1998. 679-700.