Teen pregnancy can be difficult under the best of circumstances, but it can be especially hard for young women in the foster care system. Nearly 160,000 adolescents live in foster care or with relatives other than their parents, in most cases as the result of abuse and neglect.¹ Teen pregnancy is all too common among this population: Young women in foster care are more than twice as likely as their peers not in foster care to become pregnant by age 19.² Even more troubling, many of those who become pregnant experience a repeat pregnancy before they reach age 19.

Although many child welfare agencies have programs that address the special needs of foster youth who are pregnant or parenting, comparatively little has been done to help foster youth avoid pregnancy. Part of the problem may be a lack of awareness and information about this high-risk population when it comes to teen pregnancy. A number of federal resources are available to help foster youth access health care and lead independent and productive lives. Advocates, child welfare agencies and policymakers are considering how these resources can be used to help adolescents in foster care delay pregnancy.

High Risk and Hard to Reach

Children typically become involved in the child welfare system after someone—often a teacher, police officer or medical provider—reports that they suspect a child is being abused or neglected. Each year, child welfare agencies respond to about two million reports of child maltreatment, and in nearly one-quarter of these cases, at least one child is found to be a victim.³ Most of these children are able to remain in their homes, where child welfare services work with families to prevent future instances of child abuse and neglect. But roughly 20% of children who are victims of abuse or neglect are placed in foster care or with relatives.

Young people who are involved in the child welfare system have long been recognized as a population at high risk of health problems, both physical and emotional. In recent years, researchers, caseworkers and advocates have also been paying more attention to their sexual and reproductive health. Although no national data are available, several regional studies and a few outcome studies unequivocally report that pregnancy, childbearing and STI rates among this group are high.^1,4,5 One study with a rigorous research design is the Midwest Evaluation of the Adult Functioning of Former Foster Youth, conducted by the Chapin Hall Center for Children at the University of Chicago. According to this longitudinal study of more than 700 young people in Iowa, Wisconsin and Illinois, 33% of females in foster care had been pregnant by age 17 or 18, compared with just 14% of their peers in the general population.^6,7 Moreover, repeat pregnancies are common: By age 19, 46% of those who had ever been pregnant had experienced more than one pregnancy, compared with 34% in the general population (see chart).⁶

FOSTER YOUTH AND PREGNANCY
Young women in foster care and those who have "aged out" are more likely to experience teenage pregnancy than their peers in the general population; repeat pregnancies by age 19 are also common.
Sources: References 6 and 7.

A limited number of studies have explored some of the reasons behind the elevated rates of teen pregnancy and STIs. Although the evidence on sexual risk behaviors is mixed, there is some evidence that foster youth, on average, first have sex at a younger age than other adolescents. A study published in the September 2009 issue of Children and Youth Services Review used data from the National Survey on Child and Adolescent Well-Being to examine sexual behaviors among nearly 900 youth in the child welfare system—some of whom had a history of foster care and others of whom remained with their birth parents. Almost 20% of youth in the child welfare system (15 years of age, on average) reported first having consensual sex at or before age 13, compared with 8% of 9th–12th graders in the general population (a somewhat older population).^5,8

Another explanation may be that youth in foster care are not as motivated as their peers to delay childbearing. According to a focus group study of 120 foster youth conducted by the Uhlich Children's Advantage Network (UCAN) and the National Campaign to Prevent Teen and Unplanned Pregnancy, having a child is a way for some foster youth to create the family they did not have or fill an emotional void.⁹ This might explain why more than one-third of young women in the Midwest study who experienced pregnancy described themselves as "definitely or probably wanting to get pregnant."⁶ Moreover, researchers point to evidence showing that teenagers who feel highly connected to their parents—teenagers who report that their parents are warm, caring and supportive—are far more likely than others to use contraception and to delay sexual activity, and are less likely to become pregnant.¹⁰ Youth in foster care, of course, often lack these kinds of protective relationships.

Indeed, instability is too often a way of life for many youth in the foster care system, making it all the more difficult to reach them with pregnancy prevention services. The care they receive is often sporadic and disjointed because of high turnover of caseworkers, changes in supervision and living arrangements, and lack of coordination among various agencies.¹¹ Although foster care is intended to be a temporary safety net (and in fact most children and youth eventually are reunified with a birth parent or find a safe, permanent home through adoption or guardianship), many youth have extended stays in the foster care system. Of the 700,000 children and youth served by foster care services each year, about 424,000 are still in care at the end of the year.¹² Fifty-eight percent of children are in foster care for more than a year, and 23% for three or more years; 11% "age out" of the system by age 18 or 21 (depending on state policy) without a safe, permanent family.¹

Federal Spending for Foster Youth

The first federal grants for child welfare services date back to 1935, when President Roosevelt signed the Social Security Act into law as part of the New Deal. Since then, this body of policy has evolved to stress various themes and services.

The Federal Foster Care Program

The modern foster care system was essentially created in 1980, when Congress enacted the Adoption Assistance and Child Welfare Act. This landmark legislation established Title IV-E of the Social Security Act, a permanently authorized and open-ended entitlement program that provides federal reimbursement to states for a portion of the cost of maintaining eligible children in foster care—for such items as food, clothing and shelter, as well as administrative costs.

Federal, state and local governments spend upwards of $23 billion each year to protect children from abuse and neglect.¹³ States use a variety of funds for child welfare services, but Title IV-E sets the policy and governs the federal foster care program across the nation. To claim federal reimbursement for children and youth in foster care, states must meet certain requirements, many of which have to do with efforts to ensure the health and safety of children and with moving children from foster care into safe and permanent homes as quickly as possible. Of particular interest to advocates concerned about pregnancy among youth in foster care, state welfare agencies are required to assess the health of children and youth entering foster care and to create a health care plan for each child, including a schedule for screenings and ongoing health care services. Moreover, children and youth in foster care are, by definition, eligible for Medicaid, the government's health insurance program for the poor, which provides reimbursement for contraceptive services and for STI testing and treatment, among other preventive services. States are currently allowed to extend Medicaid coverage to foster youth up to age 21. This has been expanded even further under the health care reform law, and starting in 2014, Medicaid coverage will be extended up to age 26 for former foster youth.

Fostering Independence

Over the past decade, federal legislation has focused on helping older adolescents make the transition from foster care to independent living. The John H. Chafee Foster Care Independence Program, enacted in 1999, recognized the need for continuing support past age 18 by encouraging states to provide a range of social services—such as vocational training, job placement and financial management skills—to youth aging out of foster care up to age 21. The Fostering Connections to Success and Increasing Adoptions Act, enacted in 2008, expanded this support by allowing states to use federal funds to provide foster care, adoption and guardianship assistance for eligible youth past age 18 and up to age 21.

The Fostering Connections Act includes several other provisions that may also help foster youth delay pregnancy and childbearing. It requires states to help adolescents develop a transition plan for themselves as they age out of foster care. Guidance issued by the Administration on Children, Youth and Families (ACYF), which oversees the foster care program, says that this transition plan should be personalized at the direction of the child. It can include specific options regarding housing, health insurance, education, local opportunities for mentors and employment services. Importantly, the guidance also encourages caseworkers to work with youth to "include information in the plan relating to sexual health, services, and resources to ensure the youth is informed and prepared to make healthy decisions about their lives."¹⁴

The Fostering Connections Act also requires state child welfare agencies to develop a plan, in coordination with the state Medicaid agency and other health care experts, for ongoing oversight of health care services for youth in foster care. ACYF guidance stipulates that this plan "must include an outline of a schedule for initial and follow-up health screenings (inclusive of age-appropriate sexual health screenings for youth)."¹⁴ Moreover, states can use federal funds to expand training for foster parents, guardians and child welfare workers on issues confronting adolescents preparing for independent living, including pregnancy prevention, healthy relationships and sexual health.

Dedicated Teen Pregnancy Prevention Initiatives

In addition to the provisions included in the Title IV-E foster care program, several new teen pregnancy prevention initiatives may also help foster youth delay pregnancy. In September 2010, the Department of Health and Human Services announced the award of $155 million in teen pregnancy prevention grants to states, nonprofit organizations, school districts and others. These grants will support the replication of teen pregnancy prevention programs shown to be effective through rigorous research, as well as the testing of new, innovative approaches to combating teen pregnancy. The funds come from two different programs. One hundred million comes from a teen pregnancy prevention program appropriated by the Consolidated Appropriations Act, 2010, which replaced the community-based grants for abstinence-only education. It is administered by the Office of Adolescent Health within the Office of the Assistant Secretary for Health. Fifty-five million comes from the Personal Responsibility Education Program (PREP), funded under the Affordable Care Act and administered by ACYF. The PREP program, in particular, holds great promise for better understanding the pregnancy prevention approaches that work with youth in foster care. Under the statute, states must use these funds for programs that reach youth most at risk of pregnancy, including those who are homeless, out of school or in foster care.

Advancing the Ball

Despite these brief mentions in law, child welfare programs seldom address teen pregnancy prevention, and teen pregnancy prevention initiatives seldom focus on the special needs of youth who have spent time in the foster care system. Moving forward, it is clear that these separate worlds of policy and practice need to be more explicitly connected.

An important first step would be for child welfare agencies to implement a comprehensive pregnancy prevention strategy. In recent years, several national organizations have, in their own ways, provided guidance on the basic components of such a strategy. For example, in 2010, the National Campaign to Prevent Teen and Unplanned Pregnancy, along with the American Public Human Services Association and the National Association of Public Child Welfare Administrators—two organizations that together represent state health, human services and child welfare agencies—developed an assessment tool for child welfare professionals that includes sample action steps.¹⁵ And a 2009 report by the California-based Public Health Institute (a nonprofit public health research organization) on the sexual and reproductive health needs of California's foster youth includes nine recommendations for child welfare agencies based on interviews with former foster youth, foster parents and foster care system professionals.¹⁶

The recommendations proposed by these national organizations may be grouped into four major categories: access to sex education, training for caseworkers and foster parents, access to sexual and reproductive health services, and increasing understanding of the root causes of early childbearing among youth in foster care.

Access to Sex Education

Many foster youth miss out on school-based sex education—even when it is offered—because of frequent changes in foster placements and lapses in school attendance. Also, there is some evidence that foster care adolescents may not always have permission to participate in these classes because of the religious views of their caseworkers or foster parents.¹⁷ Religiously affiliated organizations and religious foster parents have been and continue to be essential partners in many communities' child welfare services, and some of these organizations and foster parents are socially conservative and may be a barrier to information and services. Little wonder, then, that many youth in the foster care system report that although they get some information about their sexual and reproductive health, it is often too little and too late.⁹

Child welfare agencies developing and implementing a comprehensive pregnancy prevention strategy should underscore the importance of providing youth with age-appropriate, medically accurate and comprehensive sex education, and they should discuss the benefits of sex education with caseworkers and foster parents. Agencies wanting to implement evidence-based programs of their own, however, may find their options limited. Very few sex education programs have been adapted to meet the unique needs of youth in foster care, and none to date have been evaluated. That may be about to change: The two largest federal teen pregnancy prevention initiatives are supporting several programs focused on reducing risky sexual behaviors among youth in foster care and will be evaluating these interventions. "It's encouraging to see the diversity of states and programs that have taken notice of the fact that young people in foster care are at high risk of teen pregnancy and need attention," says Itege Bailey, senior manager with the National Campaign to Prevent Teen and Unplanned Pregnancy.¹⁸

Experts acknowledge, however, that more options are needed. Although at least one evidence-based program has been adapted for foster youth, it is designed for teens in group settings—group homes, residential facilities or transitional living programs. "Alternative strategies may be needed for youth in other settings," says Amy Dworsky, a senior researcher at the University of Chicago's Chapin Hall and coinvestigator for the Midwest study. "We need to know how to reach kids who aren't always in school, who may be scattered throughout the community or who live in rural settings."¹⁹

Training for Caseworkers and Foster Parents

Child welfare workers play a critical role in helping youth and their families access the services and supports they need. But many feel unprepared to talk with foster youth and parents about sex, relationships and prevention, and frequent staff turnover is an ongoing challenge. By focusing on training of caseworkers, child welfare agencies would go a long way toward addressing sexual and reproductive health needs of foster youth. This training could include ways of engaging youth as well as foster parents in discussions about sex. Caseworkers also need information about state confidentiality policies, resource toolkits, quality Web sites and referral networks. Child welfare agencies need not go it alone; they can partner with organizations (such as a local health department or family planning clinic) within the community that can provide this expertise.

A similar case could be made for training foster parents and guardians. Foster parents should routinely initiate discussions with youth around issues related to sexuality, including self-image, relationships, goal setting, planning and decision making, and protection from STIs, unwanted pregnancy and exploitation. To do this, foster parents need training in how to have these regular discussions.

Access to Services

Child welfare agencies have systems in place to make sure that youth in foster care get the health care they need. Some states also have policies requiring medical providers to address sexual activity, pregnancy prevention, and STI screening and treatment with foster youth. It is not known, however, to what extent child welfare agencies and health care providers incorporate these services into the ongoing health care that foster youth receive.

Child welfare agencies need to take steps to ensure that foster youth are informed of the availability of sexual and reproductive health services and know where to go for these services. This may mean better coordination with state Medicaid agencies, special training for medical providers who see foster youth or establishing strong referral networks with family planning clinics. Because some foster youth may feel intimidated or embarrassed accessing contraceptives through their doctor, child welfare agencies should also consider ways of offering contraceptives through independent living program sites, youth development centers and other youth-serving agencies.

Increasing Understanding

A recently launched survey of youth in the foster care system promises to shed new light on early childbearing among this population. Created by the John H. Chafee Foster Care Independence Program, the National Youth in Transition Database is designed to track youth as they transition from the foster care system to independent living. State child welfare agencies will interview teens on or around their 17th birthday, and again at ages 19 and 21, about a range of issues they may face—from educational attainment to experience with homelessness to access to health insurance. These state agencies will also ask foster youth whether they have had a child or fathered a child, and some will be collecting information about teens' contraceptive use. The survey was launched in October 2010, and state agencies are expected to submit the first round of data to the Administration for Children and Families in May 2011.

This new survey may be an important way to raise awareness and garner support for pregnancy prevention for youth in the foster care system. It is also a critical first step toward understanding how pregnancy and childbearing are intertwined with such profoundly difficult issues as the absence of a dependable family or social network, homelessness and educational deficits. In that regard, experts stress that a deeper understanding of the root causes of early childbearing among this population is also needed. "Information about and access to birth control is essential but not sufficient," says Dworsky of the University of Chicago. "We can provide youth in care with all the contraception in the world, but pregnancy rates among this population will remain exceptionally high unless the factors that motivate so many of these adolescents to become pregnant are addressed. For some youth in foster care, having a child may be seen as a way to create a family of their own, a family who will love them and who they can love, or to demonstrate that they can do a better job of parenting than their birth parents had. Addressing these motivations means giving teens in foster care a reason to delay pregnancy and childbearing. They need to believe that they can complete their education, find a good job and succeed in life."¹⁹

Budget Battles Ahead

In many ways, the basic policy framework needed to support interventions to reduce teen pregnancy among young women in foster care is already in place at the federal level. For example, the health care plans that child welfare agencies are required to develop for each child, the transition plan and assistance for youth who are aging out of the foster care system and the federal teen pregnancy prevention initiatives are all opportunities for helping foster youth delay pregnancy. Moving forward, child welfare agencies and program planners should be thinking about ways to maximize these levers to address the sexual and reproductive health needs of foster youth.

At the same time, intense pressure to hold down government spending, at both the federal and state levels, is likely to continue unabated in the months and perhaps years ahead. And there are already indications that the impact is likely to be felt most by disadvantaged populations, whose needs are at best underrepresented in Washington and state capitals. According to an analysis by the Center on Budget and Policy Priorities, roughly two-thirds of the proposed cuts included in the House Budget Committee's 2012 budget outline are to programs serving low-income children and families.²⁰ These cuts have the potential to jeopardize a variety of critical services for youth in foster care, sexual and reproductive health services included. In short, although child welfare agencies may be better poised to address the sexual and reproductive health needs of foster youth than ever before, the budget process is moving in the other direction. Clearly, foster care advocates and service providers have their work cut out for them.

REFERENCES

1. Children’s Bureau, Administration on Children, Youth and Families, The AFCARS Report: Preliminary FY 2009 Estimates as of July 2010, 2010. <http://www.acf.hhs.gov/programs/cb/stats_research/afcars/ tar/report17.pdf>, accessed Apr. 14, 2011.

2. Courtney ME et al., Midwest Evaluation of the Adult Functioning of Former Foster Youth: Outcomes at Age 19, working paper, Chicago: Chapin Hall at the University of Chicago, 2005.

3. Children’s Bureau, Administration on Children, Youth and Families, Child Maltreatment 2009, 2010, <http://www.acf.hhs.gov/programs/cb/pubs/cm09/cm09.pdf&gt;, accessed Apr. 14, 2011.

4. Ahrens KM et al., Laboratory-diagnosed sexually transmitted infections in former foster youth compared with peers, Pediatrics, 2010, 126(1):97–103.

5. James S et al., Sexual risk behaviors among youth in the child welfare system, Children and Youth Services Review, 2009, 31(9):990–1000.

6. Dworsky A and Courtney ME, The risk of teenage pregnancy among transitioning foster youth: implications for extending state care beyond age 18, Children and Youth Services Review, 2010, 32(10):1351–1356.

7. Courtney ME et al., Midwest Evaluation of the Adult Functioning of Former Foster Youth: Outcomes at Ages 23 and 24, working paper, Chicago: Chapin Hall at the University of Chicago, 2010.

8. Centers for Disease Control and Prevention, Youth risk behavior surveillance—United States, 1999, Morbidity and Mortality Weekly Report, 2000, Vol. 49, No. SS-5.

9. Love LT et al., Fostering Hope: Preventing Teen Pregnancy Among Youth in Foster Care, Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy, 2005.

10. Resnick M et al., Protecting adolescents from harm: findings from the National Longitudinal Study on Adolescent Health, Journal of the American Medical Association, 1997, 278(10):823–832.

11. Allen K, Medicaid managed care for children in child welfare, Issue Brief, Hamilton, NJ: Center for Health Care Strategies, 2008, <http://www.chcs.org/usr_doc/CW_MC_Brief.pdf&gt;, accessed Apr. 14, 2011.

12. Children’s Bureau, Administration on Children, Youth and Families, Trends in foster care and adoption—FY 2002–FY 2009, no date, <http://www.acf.hhs.gov/programs/cb/stats_research/afcars/ trends02-09.pdf>, accessed Apr. 14, 2011.

13. Scarcella CA et al., The Cost of Protecting Vulnerable Children V: Understanding State Variation in Child Welfare Financing, Washington DC: The Urban Institute, 2006.

14. Children’s Bureau, Administration on Children, Youth and Families, Guidance on Fostering Connections to Success and Increasing Adoptions Act of 2008, 2010, <http://www.acf.hhs.gov/programs/cb/ laws_policies/policy/pi/2010/pi1011.pdf>, accessed Apr. 14, 2011.

15. National Campaign to Prevent Teen and Unplanned Pregnancy, American Public Human Services Association and National Association of Public Child Welfare Administrators, Effective planning for child welfare leaders to help prevent teen pregnancy: an agency assessment, Briefly…, 2010, <http://www.thenationalcampaign.org/ resources/pdf/Briefly_EffectivePlanning_ChildWelfareLeaders.pdf>, accessed Apr. 14, 2011.

16. Center for Research on Adolescent Health and Development, Public Health Institute, Sexual health challenges of California’s foster youth, No Time for Complacency Policy Review, 2009, <http:// teenbirths.phi.org/2009SpringPolicyReview.pdf>, accessed Apr. 14, 2011.

17. Constantine WL et al., Sex Education and Reproductive Health Needs of Foster and Transitioning Youth in Three California Counties, Oakland: Center for Research on Adolescent Health and Development, Public Health Institute, 2009.

18. Bailey I, National Campaign to Prevent Teen and Unplanned Pregnancy, Washington, DC, personal communication, Apr. 15, 2011.

19. Dworsky A, Chapin Hall at the University of Chicago, Chicago, personal communication, Apr. 26, 2011.

20. Greenstein R, Chairman Ryan gets roughly two-thirds of his huge budget cuts from programs for lower-income Americans, Washington, DC: Center on Budget and Policy Priorities, 2011, <http://www.cbpp.org/files/4-5-11bud2.pdf&gt;, accessed Apr. 14, 2011.