Teen pregnancy is not a public health crisis in the United States. It is time we made it one

Strictly speaking, Lawlor and Shaw are correct. After adjusting for family background, race/ethnicity, socioeconomic position, educational success, and future prospects, many US studies show that teen mothers are as likely as older mothers to bear and raise healthy, successful children.1–6 After adjusting for being born to Texas oil barons and educated at Andover and Yale (throw in effect modification by paternal occupation), might you or I be the leader of the free world? Sure. The sanitary appeal of our modelling exercises can blind us to the sheer common sense of crude numbers. Teen parenthood is still associated with infant mortality, childhood illness, welfare dependence, academic failure, juvenile crime, and teen parenthood in generations to follow.7,8 This is not to deny the importance of research into the causes and effects of teen pregnancy. Indeed, it is testimony to the increasing strength of epidemiological methods that maternal age can be stripped from its tight association with economic and social risks, yielding the conclusion that teen pregnancy (at least for the 98% of teen pregnancies that occur after age 14 in the US)9 poses little, if any, inherent biological risk in the developed world. Such studies implicate poverty, not maternal age, as the real threat to maternal and infant welfare. It is not just the disadvantaged, but the ‘discouraged among the disadvantaged’ who become teen mothers.10 Poverty causes teen pregnancy. Simply put, girls with prospects do not have babies. But does premature parenthood cause future poverty? Remarkably, with appropriate control for economic background and educational attainment prior to pregnancy, it appears that the life trajectories of teen mothers are little altered by becoming mothers in their teens.5,11 Circumstances were not about to improve for these young women, even if they had postponed pregnancy into their twenties. In the words of one Boston teen, ‘Why should you wait? Who's coming?‘12 Under these circumstances, it would make little, if any, difference to US public health if teen mothers were to wait a few years. Indeed, where cumulative exposure to poverty and stress degrades maternal health capital, risks of poor pregnancy outcome may actually rise with maternal age.13 Arline Geronimus has argued that in the face of such powerful weathering forces, it makes sense for disadvantaged women to bear their children in their teens.14 These data indict a society in which many youth face prospects so bleak that the conventional credentials of adulthood, a high school degree and a job, are rendered nearly worthless. Where there is no opportunity, there is no cost to early parenthood. However, there is a corollary: increase opportunity, and the cost of early parenthood rises. Teens appear to be rational beings who, given the motivation and the means, will exploit opportunity by delaying parenthood long enough to gain a social and economic foothold. Hence the success of some teen pregnancy prevention and parenting programmes, which provide both motivation and means to escape poverty and delay parenthood.15,16 Teens may also be motivated by real or perceived changes in the economy: some have argued that the decline in the US teen pregnancy rate over the last decade was a by-product of economic expansion.17 So where is the public health crisis? If there is a real health cost of teen pregnancy, we are hard put to measure it. Our best estimates remain fraught with confounding and selection bias. However, common sense tells us that there is large and elastic margin of teens who can correctly self-select themselves out of a future of poverty and ill health, given a chance to enhance personal and job skills, and with full access to contraception and abortion services. These constitute the means to escape poverty and early parenthood. The motivation to delay parenthood springs from real local opportunities. We must create environments in which educational attainment matters, jobs have living wages, and it simply makes sense to avoid premature parenthood. We need to make teen pregnancy a real public health crisis. What is the alternative? To dismiss the needs of today's and tomorrow's teen mothers because their counterfactuals would not have amounted to much? The crude data demonstrate that teen mothers need opportunities and tools to escape poverty; the adjusted data show us that self-selection will prevent teen pregnancy where such opportunities and tools exist. The equalizing power of our adjusted statistical models can be beguiling. Let us not forget that the real world is not a level playing field, that equal opportunity remains a polite national fiction, and that statistics alone will not loosen the sickly embrace of poverty and teen pregnancy.