Success in School: Efforts to Improve Education for Students who are Pregnant, Parenting or Survivors of Violence

Pregnancy and parenthood does not have to mark the end of education for young men and women. Yet, according to the National Women’s Law Center, nearly half of all female dropouts say that becoming a parent played a role in their decision to leave school, and 33% of female dropouts said pregnancy was a major factor. Additionally, 24% of male say that becoming a parent played a role in their leaving school, and 19% said it was a major factor.

Life becomes increasingly difficult for young parents who drop out of school. Only 51% of women who have a child before age 20 earn a high school diploma before age 22. Education prospects for pregnant or parenting young women become bleaker at the higher-education level. Two percent of women who have a child before age 18 earn a college degree by age 30. This lack of education means that young parents who drop out of school are more likely than their peers to be unemployed or underemployed, and those who obtain work, earn significantly less than their peers who graduate from high school.

These statistics and studies were recently reviewed at a Town Hall held by The Illinois Caucus for Adolescent Health (ICAH) following the national release of the U.S. Department of Education’s recommendations to support the academic success of pregnant and parenting students under Title IX.

Image from ICAH

Image from ICAH

Before Congress passed Title IX in 1972, pregnant or parenting students were often discriminated against and sometimes dismissed from high school. Title IX prohibits sex discrimination, including on the basis of pregnancy, childbirth, and parental status.

The recommendations in the Office of Civil Rights’ June 2013 publication include:

  • A pregnant student must be allowed to remain in her regular classes and school if she chooses. Any alternative arrangement must be comparable to the regular school program in academic, extracurricular and enrichment opportunities.
  • Schools must treat pregnant students in the same way that they treat other students with temporary medical conditions. Thus, any special services and arrangements in place must also be provided to pregnant students, such as at-home tutoring and extensions on assignments.
  • A school must excuse a student’s absences because of pregnancy or childbirth for as long as the student’s doctor deems the absences medically necessary. When a student returns to school, she must be allowed to return to the same academic and extracurricular status as before and have the opportunity to make up missed work. Similarly, parenting students must have excused absences when they need to care for sick children or take them to doctors’ appointments.
  • A school must provide assistant to a pregnant or parenting student, such as providing a larger desk or designating a private room for breastfeeding during the school day.
  • A school must be aware and ensure that their teachers and staff follow Title IX requirements and know their rights. This may involve collaborating with a school district’s Title IX coordinator to provide workshops for administrators on laws related to the provision of services to pregnant and parenting students. A grievance procedure must be in place and adhered to by students, parents, and employees.
  • Schools must work with pregnant and parenting students to create a graduation plan tailored to each student’s needs. This may include an academic credit-recovery option for parents who take time off from school or the option for dropouts to return to school.

Although the recommendations focus on secondary schools, the statues apply to all recipients of federal funds, including post-secondary institutions.

Efforts to pass state-level legislation to ensure these and other protections have also been ongoing — the Ensuring Success in Schools Act was first introduced in 2007. This legislation would promote successful school completion for pregnant and parenting students as well as those affected by domestic or sexual violence by:

  • enabling expectant and parenting students as well as student victims of domestic or sexual violence to succeed in school;
  • providing guidance to school districts in responding to and alleviating the barriers to academic success for students who are parents, expectant parents, or survivors of domestic or sexual violence;
  • encouraging the safe and meaningful involvement of parents of students.

A state-designated Ensuring Success in Schools Task Force issued a report in 2010 which made recommendations for accomodating and supporting pregnant and parenting students, but also made recommendations for policies affecting student survivors of domestic and sexual violence. According to the report:

Students who experience dating violence or sexual harassment have a hard time paying attention in school and often participate less in class or do not go to class at all, whether the violence happened on or off school grounds. Testimony at Task Force hearings indicated that student survivors of sexual violence experienced sharp declines in grades following incidence of violence. Witnesses told stories of schools that refused to respect orders of protection, denied reasonable accommodations requested by the survivor, placed the burden of change and compliance on the survivor and not the perpetrator, forced the survivor to repeat her story several times and in front of other people, denied the survivor basic confidentiality, and punished the survivor for minor offenses related to the violence while overlooking the acts of violence committed by the perpetrator. Students who are survivors of domestic and sexual violence want to stay in school and graduate, but fear for their safety and well-being often forces them into involuntary homeschooling or alternative programs or forces them to drop out entirely.

In response, the authors suggested that schools:

  • waive minimum attendance requirements for students who are survivors of domestic or sexual violence and recognize absences as valid if they are due to safety concerns, to having received victim services, or to recovering from physical or psychological injuries;
  • allow students to make up missed work and provide appropriate academic supports, including the option of homebound instruction;
  • allow in-school accommodations—including changing classes, lockers, lunch hours, or any other appropriate safety measures—as necessary to facilitate school attendance and participation;
  • honor any order of protection and civil no-contact order;
  • allow student survivors of violence to transfer to another school without penalty for reasons of safety and well-being; and
  • place the burden of compliance on the perpetrator whenever possible.

Contraception & STI Prevention: What Do Young African American Men Think?

This month, researchers from the Section of Family Planning & Contraceptive Research presented results of several ongoing studies at the North American Forum on Family Planning. Dr. Elisabeth Woodhams, now a physician at Thomas Jefferson University Hospital, discussed her findings from a focus group study that sought to understand African American adolescent males’ perceived responsibility for pregnancy prevention. Dr. Woodhams also received the award for the top presentation from an investigator in training.

Dr. Elisabeth Woodhams

Dr. Elisabeth Woodhams

Men, particularly young men, are often left out of conversations about how to improve contraception use, but male partners can have significant influence over the contraceptive and pregnancy decisions of their female partners. Several studies indicate that women are more likely to stick to a chosen method if their partners know they’re using it, or if the partner is involved in the decision to use that method. The reality of this influence drove Dr. Woodhams to wonder how the partners regard this responsibility. Her study included teenaged African American males enrolled in charter schools on Chicago’s South Side. Several compelling themes emerged in Dr. Woodhams’ findings. One theme throughout was that even though the young men reported feeling responsible for the outcome of an unplanned pregnancy, it did not mean they acted to prevent pregnancy.

Focus on condoms, lacking knowledge of non-barrier methods

When asked about ways to prevent pregnancy, the most common answers were condoms, pull out, or don’t have sex. All had heard of pills, some had heard of IUDs or vaginal rings, and none knew about the contraceptive implant. Some had heard of Plan B, but often thought of it as a shot. Several quotes below reflect some of the misunderstandings about methods:

 “…I heard about one where you put it under a layer of skin in your arm. It’s called….Nuvaring.”

“She get the morning after shot and they’ll just kill all the sperm…”

“I also heard of that thing…they take the top off and put it in their vagina or whatever. Like it knock out, it blocks it. It works for years. It’s called… starts with ovulation.”

“All I heard is it goes inside them, but if you hitting it, if you playing bump around, you can knock it out of place.”

Primary role in sex was condom use and provision

Participants did know a lot about condoms, felt responsibility to provide and use a condom, and really only considered condom use when they talked about “protection.”

“…she like grabbin’ me…and just automatically stop and be like ‘you got the rubber?’ and I’m like ‘what?!’ … and most of the time I do because I always carry condoms like in my back pocket or something…”

“I take at least a third of the condoms… and I take ‘em to my girl crib. Cause I might come over there and then, you know, something might happen, I know that if I didn’t bring a condom I got somethin’ over there with her.”

STI prevention greatest motivator in condom use

STI prevention was the greatest motivator for condom use and reflected attitudes about partners.

I’mma need some condoms ’cause. Like, it wasn’t the fear of me havin’ a baby as the fear of me catchin’ something.”

 “You still use a condom. I don’t know what she got.  No matter what. Like, a girl could be on birth control all her life.  She could be on the best birth control. I’m still not gon’ go in raw.”

“Even before you get down to the having sex part you should always ask a girl when the last time she got checked up.”

Partner type, access, and family indirectly impacts condom use

Motivation to use condoms in a specific sexual encounter was indirectly mediated by several things, the most notable being the “type” of girl they’re having sex with, access to condoms, and family influence. The vast majority of the conversations were actually about the various names and terms the teens had for the girls they have sex with. For instance, “thots” were considered “dirty girls” who sleep with anyone, are likely to have an STI, and are not worthy of respect. “Mains” are a more regular partner, although not necessarily a monogamous partner.  Young men behaved differently when they were with casual partners than when they were with more regular partners, who in general they spoke about with more modesty and respect. With regular partners they often would forgo condoms, but several guys mentioned going to get STI testing with their partners before they made that leap. They did not universally mention discussing pregnancy prevention, although some did.

“Mod: If the thot’s like ‘man, come on get down, but you can’t use nuttin’.” Resp: “If we don’t use it then we ain’t doin’ it. Point blank.” Mod: “Okay. But wit’ yo main you not that way.” Resp: “mmm-mmm [MEANING NO]“.

“But, when it comes to like fuckin’ thots …you don’t know who they be fuckin’, you don’t know what they got, so you always wanna be protected.”

Access was also an issue, both in terms of immediate access and terms of cost and availability. As one participant observed, “We in the basement, I know I ain’t got no condoms, they’re upstairs. I’m not about to go to the 3rd floor, leaving a thot downstairs.”

Finally, participants referred to the women in their family as motivators to protect themselves, more from STIs than from pregnancy. They generally felt comfortable telling their family they were having sex, and depended on their mothers/grandmothers/aunts to provide condoms.

 “Like when you first talk to yo’ moms about it, you don’t wanna tell her cause feel like somethin’ bad gon’ happen. But after you tell her it turns out different…she gonna force condoms on you because she don’t want her child to catch no disease…”

Responsible for pregnancy, but not prevention

While the participants did not prioritize pregnancy prevention, when asked directly whose job it is to prevent pregnancy they reported it was a shared responsibility. However, if pregnancy happened, it was mostly the young man’s fault, especially if they weren’t using a condom. They feared unplanned pregnancies and felt a very strong sense of responsibility if pregnancy happened – this often came out within the context of manhood. When they talked about unplanned pregnancy there was a sense of helplessness; they weren’t interested in fathering but there was little they could do about it aside from use condoms.

 “And I shoulda used a condom. And basically, I’mma have to like get two jobs and like I can’t like, I’mma have to finish school so I could get a better job and I’m not even ready yet.  And you thinkin’ all of this, and how your parents is gon’ react. And you havin’ a child. Like how that’s gon’ make you growin’ up so much faster and your life is basically through.”

 “With the guy he has to know that he has two options that he can take.  Face it like a man or basically run away.  Run away and then he has that title saying ‘you a coward, you’re not a man that gon’ step up to the challenge of taking care of a child.’  But if he stays there he knows that he has to be dedicated, committed, make a sacrifice in his life.”

Conclusions

Dr. Woodhams found the young men in the study were much more focused on STI prevention rather than pregnancy prevention, even though they would feel responsibility if a pregnancy occurred. The concern for STIs prompts condom use, but if they believe their partner is low-risk, they will also stop using condoms. Dr. Woodhams suggested that one approach would be to leverage awareness and comfort with condom use among these young men to emphasize that condoms can also be part of pregnancy prevention. While other contraceptive methods may be more effective, young men may respond more positively to education about a method they already use. In addition, Dr. Woodhams observed that the young men perceived their sexual relationships completely based on risk, rather than on the relationship they were in with their partner. In fact, they rarely referred to a relationship at all, but easily categorized the young women they were having sex with into “good” or “bad,” “clean” or “dirty.” She suggested that sex education programs work to emphasize healthy and fulfilling relationship-building and respect as a response to these attitudes and their influence on condom use.

Contraception as Preventive Medicine

Updates in Clinical Care provided by The Ryan Center at the University of Chicago

An Ounce of Prevention 
Given the current climate of change and controversy surrounding contraceptive access, we should once again examine the importance of contraception as a tool for preventive medicine.

Contraception is the key to prevention.
More than half of all US women will experience an unintended pregnancy at some point in their lives, and nearly one-third will have an abortion (1, 2). Unfortunately, the rate of unintended pregnancy in the United States has seen no improvement in recent years, and there was a slight increase from 2001 to 2006, from 50 to 52 per 1,000 reproductive-aged women. Poor and low-income women are at even higher risk of unintended pregnancy: the rate for women at or below the poverty limit is 66 per 1,000 women, compared to 10 per 1,000 women who are at >200% of the poverty limit (1).

Although incorrect and inconsistent use of contraception account for some unintended pregnancies, the majority (52%) occur among the small percentage of women (16%) who are not using any contraception (3).

On a note of positive change, we have seen teen pregnancy in the United States decline significantly since the mid-1990s. Although abstinence has played a role, several analyses have confirmed that contraception is responsible for the majority of the decline in teen pregnancies (4, 5). To review some of the latest research in the area of contraception, see recent studies highlighted on our Reproductive Health & Justice Research blog.

Increasing access to contraception, especially highly effective methods of contraception, is a vital public health issue.

1.  Finer LB and Zolna MR, Unintended pregnancy in the United States: incidence and disparities, 2006, Contraception, 2011, 84(5):478–485.
2.  Jones RK and Kavanaugh ML, Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion, Obstetrics & Gynecology, 2011, 117(6):1358–1366.
3.  Gold RB et al., Next Steps for America’s Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System, New York: Guttmacher Institute, 2009.
4.  Santelli J, et al. Explaining Recent Declines in Adolescent Pregnancy in the United States: The Contribution of Abstinence and Improved Contraceptive Use, Am J Public Health, 2007, 97:150–156.
   5.  Teen Births at Record Low Thanks to Improvements in Contraceptive Use, New York: Guttmacher Institute, April 11, 2012, available at: http://www.guttmacher.org/media/inthenews/2012/04/11/index.html.

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The Ryan Center & Contraceptive Care
We are pleased to announce two new exciting programs offered by the Ryan Center.

Carol’s Contraceptive Access Project (CCAP)
Due to a generous donation, we are now able to provide contraception for patients at the Ryan Center, regardless of insurance or ability to pay. We have low-cost options and financial assistance for:

  • Immediate insertion of intrauterine devices and implantable contraception (e.g. Implanon®)
  • Same-day injections of Depo-Provera®
  • Combined hormonal contraceptives (the pill, patch, and ring)

Center for Contraceptive Management
We offer the full range of contraceptive options, including, but not limited to:

  • Intrauterine device (IUD) and Implanon®/Nexplanon® insertion
  • Depo-Provera injections
  • Surgical and “no-cut” Essure® tubal sterilization
  • Prescriptions for: oral contraceptive pills, the contraceptive vaginal ring (NuvaRing®), the contraceptive patch (Ortho Evra®), and emergency contraception

      *We specialize in contraception for medically complicated patients.

Contact us at 773-702-6118 to make an appointment.

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IUD Clinical Trial
Are you or your patient interested in receiving an investigational IUD for long-term birth control? Participants will be compensated up to $900 over the course of 5 years. Click here for more information. UPDATE: This study is now closed.

Race and Reproductive Politics: An Editorial

In Race, Reproductive Politics and Reproductive Healthcare in the Contemporary United States, an editorial published in Contraception, authors Carole Joffe and Willie Parker discuss how the United States, a country marked by extreme stratification on both racial and economic grounds, has had a history of both targeting the birth rates of people of color while also fueling deep political divisions about the provision of reproductive healh services – particularly abortion and contraception.

The authors discuss their dismay at the contemporary state of reproductive politics in the United States, particularly the manipulation of racial themes by opponents of abortion and birth control.  However, they reference the “mixed legacy” of the United States history and acknowledge the complexity of alandscape “containing both liberatory and coercive possibilities, and always with particular implications for people of color in a white-dominated society.” Ultimately, the authors warn against the “manipulation of the history of race and reproduction by those involved in the [recent anti-abortion] billboard campaigns” and similar efforts which obscure “the contemporary facts of life faced by the most vulnerable black women.”

The authors note that the current climate has galvanized a countermovement of health activists  and they see hope for women’s reproductive rights. At the same time, the authors conclude that “the stakes in this “war” are inevitably the highest for the most vulnerable in our society; Parker calls on fellow health care providers “to trust women to make the good and tough decisions about when and whether to expand their families” and assure them the resources to do so.

Adolescent Initiation of Sexual Activity

In Sexual Timetables for Oral-Genital, Vaginal and Anal Intercourse: Sociodemographic Comparisons in a Nationally Representative Sample of Adolescents, published in The American Journal of Public Health, authors Carolyn Tucker Halpern and Abigail Haydon documented the relative timing and prevalence of three types of intercourse: oral-genital, vaginal, and anal, examining whether these timetables varied by sociodemographic factors.

The authors utilized data from National Longitudinal Study of Adolescent Health respondents to generate prevalence estimates for adolescents who reached age 18 years by 2001, examining sociodemographic correlates of sexual patterns.

Authors found that 1 in 5 adolescents did not engage in any of the aforementioned sexual behaviors by age 18 years, while over two thirds reported vaginal or oral-genital sexual activity.  Roughly half of respondents experienced both.  Only 10 percent of individuals reported having had an anal intercourse experience.  Authors concluded that most of the examined sociodemographic characteristics were uniquely associated with prevalence and sexual timing.

Disparities in Reproductive Care Among Urban and Rural Women

In Primary Care Physician’s Perceptions of Barriers To Preventive Reproductive Health Care in Rural Communities [PDF], published in Perspectives on Sexual and Reproductive Health, authors Cynthia H. Chuang, et al, sought to investigate the disparities in reproductive health care between urban and rural women.

Findings suggest that expanding access to preventive reproductive health services in rural areas may not be sufficient to improve use of contraceptive services and preconception care.  Raising public awareness of the importance of pregnancy planning and good preconception health is needed.

In 2010, authors conducted semistructured interviews with 19 rural primary care physicians in central Pennsylvania regarding their experiences in two domains of preventive reproductive health—contraceptive care and preconception care. Physicians perceived that they had a greater role in providing contraceptive care than did nonrural physicians and that contraceptives were widely accessible to patients in their communities; however, the scope of contraceptive services that were provided by each individual provider varied greatly.  Physicians also perceived rural community norms of unintended pregnancies, large families, and indifference toward career and educational goals for young women as the biggest barriers to both contraceptive and preconception care, as these issues predicted a lack of interest in family planning.

Study findings point to the importance of encouraging primary care physicians to take a more proactive role in promoting preventive reproductive health care.  This could be accomplished through continuing education programs and skills-building workshops to increase both provider knowledge about client self-efficacy for reproductive health counseling.

Minors Express Mainly Negative Opinions about Parental Notification Laws

In Abortion-Seeking Minors’ Views on the Illinois Parental Notification Law: A Qualitative Study, published in Perspectives on Sexual and Reproductive Health, author Erin K. Kavanagh and other researchers from the Section of Family Planning and Contraceptive research analyze abortion-seeking minors’ thoughts on mandatory parental involvement laws and the potential impact such a law might have on a minor’s decision and level of access to abortion services. 

In-depth interviews were conducted with 30 minors presenting for an abortion at one of three Chicago-area clinics in 2010. Interviewers described the Illinois parental notification law (which was passed in 1995 but is not in effect because of legal challenges) and a corresponding judicial bypass option to the minors and asked their opinions about them. Interviews were coded and analyzed using content analysis and grounded theory methods.

The participants believed this law would diminish minors’ reproductive autonomy and potentially expose them to unwanted pressure or interference in their abortion decision. At the same time, many felt that voluntarily seeking support from a trusted adult, but not necessarily a parent, could benefit minors. The authors suggest that policymakers might better understand the impact of parental notification laws on minors’ ability to make reproductive health decisions if teens’ voices were heard in the debates concerning these laws and question whether parental notification laws best serve the reproductive well-being of minors.

New Study Examines Association between DMPA (Depo shot) and STI Risk among Adolescents

In the article Depot Medroxyprogesterone Acetate Use is Not Associated with Risk of Incident Sexually Transmitted Infections Among Adolescent Women, published in the Journal of Adolescent Health, author Amy Romer and other researchers from the Section of Family Planning and Contraceptive Research investigated whether depot medroxyprogesterone acetate (DMPA) use is associated with an increased risk of sexually transmitted infections (STIs) in a group of healthy adolescents. The authors found no evidence that DMPA use increased risk of STIs, and the only factor significantly associated with increased risk was a greater number of sexual partners (odds ratio, range = 1.91-2.62)

Adolescent women aged 14–17 years (n = 342) were recruited from clinical sites in the United States between 1999 and 2005. They returned quarterly for interviews and STI testing. During alternating 3-month periods, participants also completed daily diaries of sexual behaviors and performed weekly vaginal self-obtained swabs to test for STIs. Data collected through 2009 (median follow-up length = 42.2 months) were analyzed.

In multivariable analysis, there were no significant associations between DMPA use in the current or previous 3-month period and incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. The only factor significantly associated with an increased risk of contracting all three STIs was a greater number of sexual partners during the diary period.

The authors conclude that in this U.S.-based cohort of adolescent women, no evidence was found that DMPA use is associated with increased STI risk. Authors recommend that efforts to curb STI transmission among adolescents should focus on education about the reduced number of sexual partners.

Reshaping Adolescent Sexual Health through Story Telling and Games

In the article From Intervention to Invitation: Reshaping Adolescent Sexual Health through Story Telling and Games, published in the African Journal of Reproductive Health, authors Melissa Gilliam, et al, from the Section of Family Planning and Contraceptive Research reviewed Game Changer Chicago. This project aims to reframe and retool adolescent sexual health education to focus on inviting rather than intervening with youth, which encourages self-empowerment that catalyzes increased awareness and self-efficacy. In addition to describing the Section’s ongoing work with sexuality education, technology and gaming, the article explores the project’s potential for successful implementation among youth in Africa.

Youth in both Chicago and Nigeria face disproportionately high rates of mortality and morbidity due to poor sexual and reproductive health. Game Changer Chicago is an initiative that incorporates digital storytelling, new media, and game design to conduct workshops with youth around issues of sexuality and emotional health. The intervention’s international, interdisciplinary team designed a series of workshops for teens to tell their stories in digital, “transmedia” formats.

Due to the positive feedback from youth participants, and the project’s promising potential to reach a wide audience online, the authors conclude that the program can continue to be successfully utilized and expanded by teens and adolescent reproductive health advocates in both domestic and international settings.

Tailored Health Messaging Improves Contraceptive Adherance

In Tailored Health Messaging Improves Contraceptive Continuation and Adherence: Results from a Randomized Controlled Trial, published in Contraception, authors Samantha Garbers, et al, conducted interventions to improve contraceptive method continuation and adherence, given that discontinuation and incorrect use of contraceptive methods may contribute to as many as 1 million unintended pregnancies annually in the United States.

The authors conducted a randomized controlled trial of 224 patients at two family planning sites which tested the efficacy of a computer-based contraceptive assessment module in increasing the proportion of patients who continued use of their chosen contraceptive method 4 months after the family planning visit.

Results indicated that family planning patients who used the module and received individually tailored health materials were significantly more likely to continue use of their chosen contraceptive method [95% compared to 77%; odds ratio (OR)=5.48; 95% confidence interval (CI): 1.72–17.42] and to adhere to this method (86% compared to 69%; OR=2.74; 95% CI: 1.21–6.21). No significant differences in these outcomes were found for participants who used the module but did not receive tailored materials when compared to the control group.

The authors concluded that tailored health materials significantly improved contraceptive method continuation and adherence, but noted that additional research on the impact of the intervention on continuation and adherence in a larger sample and over a longer follow-up period is merited.