Commentary on "A Tale of Two States
" Journal of Applied Research on
Children: Informing Policy for Children at Risk: Vol. 2: Iss. 2
Commentar y on "A Tale of Two States"
Ronna Popkin 0
0 Columbia University
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In this issue of the Journal of Applied Research on Children, Susan Tortolero and
colleagues report on the differences in declines in teen birth rates between California
and Texas over the period 1981 – 2008. In 1981, and especially in 1991, when rates of
teen childbearing peaked across the United States, both Texas and California had teen
birth rates that were higher than the nation’s average. However, between 1981 and
2008, the rate of teen births declined much faster in California (by 28%) than in Texas
(16%). By 2008, the teen birth rate in California was below the national rate, while the
rate in Texas was considerably higher. The differences between Texas and California
in the proportional declines in their rates of teen births are especially striking among
Hispanic teens: in Texas, Hispanic teen birth rates declined by only 4%, which was
considerably smaller than the 24% decline in California. Despite these declines, teen
birth rates for California, Texas, and the U.S. in 2008 remained well above rates in
Western Europe.
Tortolero et al. ascribe these different trajectories to differences in health policies
in Texas and California. In particular, they note distinct state approaches to sexuality
education, to access to contraceptive services for teens, and to public-private
partnerships. California, after a period of unsuccessful experimentation with abstinence
promotion in the early 1990s, has pursued comprehensive approaches to sexuality
education, which encourage abstinence as the safest choice, but also encourage
condom and contraceptive use for those who do have sex. In contrast, Texas has
focused on school programs that promote abstinence and restrict information about
condoms and birth control. California has also vigorously promoted access to
contraceptive services for teens and women living in poverty and has allowed teens to
receive state-funded services without parental notification. By comparison, Texas
requires parental consent for minors to access state-funded family planning services
unless they are married. While parental consent is not required to access federally
funded contraceptive services in Texas (or any state), these differences between
consent policies are likely to be confusing to adolescents and therefore may serve as a
barrier to teen access of reproductive health care.
Tortolero et al.’s conclusions are consistent with previous research. For
example, recent reviews by the Centers for Disease Control and Prevention (CDC) and
The United Nations Educational, Scientific, and Cultural Organization (UNESCO) show
strong evidence for the effectiveness of comprehensive sexuality education, but not
abstinence-only approaches.1-3 In addition, data on national trends from the 1990s and
early 2000s suggest that the consistent declines in teen birth and pregnancy rates
between 1991 and 2005 were driven primarily by improved use of condoms and other
contraception4. Previous research also has demonstrated a relationship between state
teen birth rates and state-level social factors.5-7 Unfortunately, these studies have not
disaggregated the effects of state characteristics (such as socioeconomic conditions,
racial/ethnic differences, and religious beliefs) from state policies (such as sexuality
education policies and family planning waivers).8 Thus, while the different approaches
to sexuality education and access to contraceptive services in Texas and California may
explain California’s success compared to Texas, additional research is needed.
Tortolero et al.’s research is circumscribed by the limitations of public health
data. As the authors note, limited data are available on the content of sexuality
education classes in the US over the period from 1981-2008. Instead, they used 2007
data on AIDS/HIV education from the Youth Risk Behavior Survey (YRBS) from Texas
and Los Angeles. (Los Angeles YRBS data were used because California does not
have population-based YRBS data.) In addition, California does not collect data on
abortion, making direct estimates of teen pregnancy rates impossible. Importantly, teen
fertility rose nationwide and in California and Texas in the late 1980s. This increase,
although partially explained by decreases in abortion among pregnant teens, is
otherwise poorly understood.
Tortolero et al. offer useful suggestions to Texas to help reduce rates of teen
childbearing. First, they propose providing medically accurate, comprehensive sexuality
education in Texas schools. While we wholeheartedly agree with this recommendation,
education alone is not sufficient to reduce teen birth rates. Targeting public health
efforts to areas with the highest rates, as suggested by Tortolero et al., is another widely
used public health strategy.
Tortolero et al. suggest initiating a statewide media campa (...truncated)