PRO-ACTION, POSTPONEMENT, AND PREPARATION/SUPPORT

A Framework for Action to Reduce the Rate of Teen Pregnancy in Canada

Pro-Action, Postponement, and Preparation/Support - A Framework for
Action to Reduce the Rate of Teen Pregnancy in Canada
480 KB, 65 pages, in PDF format  

Prepared for the CAPC/CPNP National Projects Fund
Health Canada

Young/Single Parent Support Network of Ottawa-Carleton
Timmins Native Friendship Centre
Canadian Institute of Child Health

September 2000

TABLE OF CONTENTS

• Acknowledgements
• Foreword
• Executive Summary

A. Introduction

• Why We're Taking Action on Teen Pregnancy
• The Partners in This Initiative
  • Young/Single Parent Support Network
  • Timmins Native Friendship Centre
  • Canadian Institute of Child Health
• Goals
• The Methodology
• Caveats and Limitations

B. Potential Consequences of Teen Pregnancy

• Uphill Climb for Parents
• Risk for the Child
• Costs to Society

C. Some Facts About Teen Pregnancy

• We're Doing Better than We Did in the Seventies, but Worse than We Did in the Eighties
• Rates are Higher Among Aboriginal Teens
• Rates are Four Times Higher Than in Many European Countries
• Teen Pregnancy Prevention Saves Money
• The Safe Sex/Contraceptive Message Isn't Getting Through to Everyone

D. Profiles of Teens Having Babies

• Teens are Differently Pre-Disposed to Pregnancy
• The "OH, NO!" Factor
• Disenfranchisement: Nothing to Lose
• Aboriginal Youth: Eroded Traditional Supports

E. Factors That Contribute to Teen Pregnancy

• Need for Effective Sex Education
• No Reason Not to Get Pregnant
• Desire to "Re-Create" Family
• Mixed Messages

F. Teen Pregnancy Myths

• "Sex education promotes sexual activity."
• "Parents oppose sex education in the schools"
• "Abstinence is the answer"
• "Once a teen becomes a parent, she and her child are doomed to a life of hardship."
• "Teens who have abortions did not want to get pregnant, while teens who keep the baby did want to get pregnant"

G. Principles Guiding the Development of the Framework

• Reduce the Rate of Teen Pregnancy in a Health Promotion Context
• Use a Health Outcomes Approach to Address a Complex Set of Factors
• Emphasize Healthy Sexuality
• Be Inclusive and Flexible
• Facilitate Co-ordinated Advice and Support
• Address the Needs of Young Males
• Encourage a Community-based Approach
• Involve Youth in Program Policy Design and Implementation

H. A Framework to Reduce the Teen Pregnancy Rate Based on Evidence of What Works

• The Framework
• Pro-Action: Having a Reason to Postpone Pregnancy
• Postponement: Having the Know-How to Postpone
• Preparation and Support: Having a Solid Foundation
• Strategies Shown to Work
  • Pro-Active Strategies
  • Postponement Strategies
  • Preparation and Support Strategies
  • National Approaches

I. Key Players in Canada

J. The Unique Role That CAPC/CPNP Projects Can Play

• Characteristics of CAPC/CPNP Projects
• Examples of What CAPC/CPNP Projects Are Already Doing
  • Terra Association
  • Healthy Babies, Bonnyville Health Unit
  • Timmins Native Friendship Centre and Community
  • Young Fathers' Program, Young/Single Parent Support Network

K. Recommendations for CAPC/CPNP Action

• Levels of Intervention
• Principles for Action
• First Steps
• Mainstream Local Community Level
  • Pro-Action
  • Postponement
  • Preparation and Support
• Aboriginal Local Community Level
  • Pro-Action
  • Postponement
  • Preparation and Support
• Provincial, Territorial and Federal Level
  • Pro-Action
  • Postponement
  • Preparation and Support

L. National Level Options

• A National Strategy for Action in Canada
  • Features of a National Strategy

M. Resources

Notes

ACKNOWLEDGEMENTS

Thank you to the Community Action Program for Children and the Canada Prenatal Nutrition Program (CAPC/CPNP) National Projects Fund, Health Canada, for its financial support of this project. Thanks also to the three project partner organizations who supported the development of this report.

We would like to thank all the CAPC/CPNP project coordinators who completed our survey requesting information on their project's role, activities, and partnerships aimed at reducing the rate of adolescent pregnancy. This information was invaluable for uncovering what was happening in communities across Canada.

Our thanks and appreciation is extended to the many individuals¹, identified as key informants from different sectors - research, academia, sex education, faith communities, teens, non-governmental organizations, Aboriginal leaders and elders, ethno cultural groups, education, recreation, politics, government, community programs and media. Your knowledge, insights and experience provided depth and richness to our understanding and deliberations.

Moreover, we would like to acknowledge the assistance and guidance received from guests² invited to two workshop sessions - representatives of Health Canada, CAPC/CPNP projects and national Aboriginal organizations - who critiqued our proposed framework for action for the reduction of teen pregnancy rates. Your feedback during these workshops indicated that we were on the right track. Thank you.

We would also like to thank Ruth Norton, an educator and elder who contributed immensely to our discussions and understanding of Aboriginal peoples' values, customs and spirituality. Funding for travel expenses provided by the Medical Services Branch enabled her to join us for two workshop days.

Our biggest "thank you" to the youth who participated in focus groups and completed surveys relating to their hopes, sexual attitudes and behaviours. Your voice was heard.

The views expressed herein are solely those of the authors and do not necessarily represent the official policy of Health Canada.

FOREWORD

This research initiative originated with a call for papers by Health Canada that resulted in four independent submissions. The proponents were subsequently asked to submit one proposal together. One organization then decided not to participate, and the remaining three became the partners for this initiative. Health Canada set the focus on its CAPC/CPNP funding program and decided that the project lead would be the Young/Single Parent Support Network.

In undertaking this initiative, we, the partners, grappled with three challenges. The first was how to address a national issue from the position of CAPC/CPNP projects with local mandates. A framework that would link local initiatives in an effective national strategy was the solution. The second challenge was how to reconcile the different perspectives of the three partners - a national organization, a local organization, and an Aboriginal northern organization. Up-front agreements on process enabled us to work together effectively, as did two consultants hired to facilitate and to prepare the final report. Our third issue was how to be inclusive of the Aboriginal peoples' perspective, given the lack of data available on Aboriginal teen pregnancy and the difficulties of adequate consultation. The inclusion of representatives from national Aboriginal organizations in workshop sessions, the participation of an Aboriginal elder and educator for two days, and a consultant hired by the Timmins Native Friendship Centre proved helpful in broaching the Aboriginal perspective.

The partners faced two additional challenges. The first was how to respect pregnant and parenting teens while talking about the prevention of teen pregnancy. The second was how to navigate the different values around such a highly controversial issue. Both these challenges were resolved by developing a framework that was as inclusive and flexible as possible, and focussed on health outcomes.

The partners are pleased to have identified a major role for CAPC/CPNP projects in future efforts arising from the framework. Their community experience and influence uniquely positions them to initiate discussion, to raise awareness, and to bring together key players in their communities to identify priorities and develop action plans

The partners believe that this document will help raise awareness about teen pregnancy and its consequences and will highlight best practices for prevention and support. We hope that this framework for action will move the issue forward, will assist with policy and program development, promote advocacy, engage youth, and inspire more research. We hope it will stimulate interest and action among Aboriginal leaders and in their communities. We see this document as a beginning and hope that strategies for reducing teen pregnancies will be linked with government child development initiatives at the federal, provincial, and municipal levels. We hope the report will assist the First Nations Child Initiative that is presently being developed. We look forward to the next steps generated by this initiative and trust that our framework will prove useful for moving ahead.

EXECUTIVE SUMMARY

This report was funded by Health Canada and developed by a group of three partner organizations - the Young/Single Parent Support Network of Ottawa-Carleton, the Timmins Native Friendship Centre, and the Canadian Institute of Child Health. The project's goal was to develop a framework for action to reduce the rate of teen pregnancy in Canada. The objectives were to learn what is currently being done and what needs to be done on this issue across the country, and to explore the potential role of projects funded by the federal Canada Action Program for Children (CAPC) and Canada Prenatal Nutrition Program (CPNP) in reducing the rate of teen pregnancy. The findings of this report are based on a literature review, a survey of 40 key informants, five consultations with youth, and a survey of 756 CAPC/CPNP projects across Canada. Special efforts were made to include the Aboriginal perspective in developing this report.

Teens have different attitudes and predispositions towards pregnancy. One group has no intention of getting pregnant and never planned on teen parenting. Another group may actually want to become pregnant. Aboriginal teens form a third group. While Aboriginal teen parenting was formerly supported by the extended family and the community, those supports have broken down, especially for urban First Nations teens. The approach to teen pregnancy prevention should be tailored to the particular needs of each of these three groups. For teens who do not want to become pregnant, emphasis should be on quality sex education and easy access to contraceptives. Teens who may welcome an "accidental" pregnancy are often those with low expectations for their future, low self-esteem, alienation within their own family, and a history of sexual abuse or poor parenting. For these teens pregnancy is often seen as a way to bring meaning to their lives. While race and ethnicity seem to be less of a factor than social class, researchers are noting a growing underclass of Canadians without economic security or opportunity. This does not bode well for teen pregnancy prevention.

Some mothers who give birth to children in their teens have made satisfactory lives for themselves and their children. However, teen pregnancy has consequences for the teen parent, for the teen's child, and for society. Statistically, teen parents are less likely to complete their education, more likely to experience isolation and homelessness, less likely to develop good parenting skills, and more likely to transfer their own history of childhood abuse and neglect to their child. Babies of teen mothers face an increased risk of pre-term birth and low birth weight, early childhood injury and acute illness, mental health problems, and eventual involvement in the criminal justice system. Aboriginal teen mothers are more disposed to substance abuse while pregnant and are less likely to be properly nourished or to breast feed their babies. The social cost of teen pregnancy includes a higher rate of school drop-out, incarceration, poverty, child abuse, and children taken into care. All of these factors have lifelong impacts.

While progress has been made, Canada could do a lot better on the issue of teen pregnancy. Statistics Canada reports that there were 38, 502 teenage pregnancies in 1996. Teen births and abortions are currently up from their historic lows, although below their historic highs. There are about four times more pregnancies among First Nations teens than among non-Aboriginals teens and 18 times more teen pregnancies on reserves. Canada's national teen birth rate is six times higher than Japan's or Switzerland's, although lower than that of the United States. Research has shown that teen pregnancy prevention saves money by averting expenditures on health, welfare, and social services. But the safe sex / contraceptive message is not getting through as well as it should. Health Canada reports that 44% of males and 43% of females between ages 15 and 19 are sexually active, but 51 % of females report having sex without a condom. Of sexually active Grade 12 students in a Nova Scotia survey, only 32% always used condoms, and 40% had two or more partners in the past year. Young girls have the highest rate of chlamydia and gonorrhea infections in Canada.

Key informants agree on a number of factors that are the main contributors to the high rate of teen pregnancy. The first factor is the need for effective sex education and free access to contraception. Key informants stressed that teens need more than information. They need practical skills for negotiating relationships and dealing with desire. Unfortunately, sex education is inconsistently delivered across Canada. Cut backs have reduced the number of public health nurses delivering sex education in schools. School teachers often tend to stick to facts about reproduction, and shy away from discussions about healthy sexuality. The second factor is the lack of opportunity that makes parenting an attractive proposition for teenage girls. The third factor is the desire among alienated girls to re-create a family that meets their need for love and belonging, and compensates for their own deficits at home, in school, or in the community. A fourth factor is the prevalence of media messages that glamorize sexuality. These messages are powerfully influential among teens who lack self-confidence. In North America, girls are more likely to associate sexual activity with spontaneity and romance - and therefore to be less prepared for safe sex.

There are a number of myths about teen pregnancy that can interfere with the development of effective public policy. For example, there is an erroneous belief that sex education will promote sexual activity among teens. Another erroneous myth is that parents do not support sex education in school.

The partners in this project consulted widely to determine principles that would guide the development of a framework for action on teen pregnancy prevention. The principles require that the framework:

• be set in a health promotion context with an overall goal of maximizing the number of children and youth who are thriving
• use a health determinants and health outcomes approach
• emphasize healthy sexuality that facilitates informed self-direction
• be inclusive and flexible so that it can be adapted by different cultural groups
• facilitate co-ordinated advice and support to vulnerable children and youth
• address the needs of young fathers
• encourage a community-based approach to action, and
• involve youth in program policy, design and implementation

The framework for action to reduce teen pregnancy is comprised of three spheres of action - pro-action, postponement, and preparation/support.

• The goal of pro-action is to reduce the percentage of teens who see having a baby as a means of meeting their psycho-social needs. Canada is failing a whole group of alienated, disenfranchised youth who have little hope for their future. Pro-action strategies build resilience in disadvantaged children and youth by strengthening social competence, problem-solving abilities, and coping skills. Successful proactive strategies include a combination of individual, school-based, and community-based interventions designed to build a strong foundation of life skills. Aboriginal peoples require a culturally appropriate approach.
• The goal of postponement is to delay first intercourse and reduce the rate of unprotected intercourse. Successful postponement strategies are those that combine good sex education with free, confidential access to contraceptives and are aimed at helping teens postpone first intercourse and using condoms and other contraceptives when they do become sexually active. Approaches that only advocate abstinence are not effective. The sex educator must be a credible person and parents must reinforce the messages around sexual health. Risk reduction depends on teens having information, motivation, and behavioural skills.
• The goal of preparation and support is to help those teens who do become pregnant and become parents to postpone subsequent pregnancies and to maximize their own healthy development and that of their child. Strategies are aimed at meeting basic living needs such as nutrition, safety, and housing, and strengthening life skills so that the parent and child can thrive. Preparation and support strategies will vary by culture and community. Successful preparation and support strategies for teen parents include home visits, enriched child development programs, nutrition and parenting programs, and neighbourhood models that promote healthy conditions for families

The key informant interviews and the project survey undertaken for this report indicate that there are already many players working effectively across Canada. They include researchers, sex educators, community service providers, youth, politicians, and members of government and non-governmental organizations. Almost all respondents supported the development of a national strategy on teen pregnancy prevention in Canada and were interested in being involved. Their main caveat was the use of a community-based rather than a top-down approach. They felt that a national strategy for teen pregnancy prevention should have a clear mandate and focus, should include youth and key players, should identify best practices, should be results-oriented, and should be sufficiently resourced to achieve outcomes.

CAPC/CPNP projects across the country are in a unique position to facilitate action on teen pregnancy prevention. Although their present focus is the preparation and support sphere of action, they are already working with high risk teens and are well-connected in their communities. They can act as catalysts for the other two spheres of action in the framework. CAPC/CPNP projects are positioned in grass-roots organizations, have influence in their communities, are innovative and experienced, have the benefit of an established federal/provincial infrastructure, understand the determinants of health approach, and are linked to the National Children's Agenda.

The partners in this initiative recommend that CAPC/CPNP projects take a leadership role in developing action plans based on the framework described in this document. Action would occur at several levels including mainstream and Aboriginal communities, and at the national, provincial or territorial level. Any planned action should focus on the well-being of children and youth, involve youth themselves, allow Aboriginals to customize their own programs, work with existing strengths, and bring programs to where youth are already meeting. First local steps would include recruiting support, meeting with key players, gathering information, holding a community meeting, and developing an action plan with a few key achievable goals. Pro-action strategies are usually targeted at neighborhoods with indicators of adolescent risk and are aimed at changing conditions and creating opportunities. Postponement strategies are generally aimed at building skills and access to services that will avoid pregnancy. Preparation and support strategies are aimed at helping teen parents and their children thrive, at promoting the prevention of subsequent pregnancies, and at preventing teen pregnancy in the next generation.

Before any action plan is developed in Aboriginal communities, the elders should be approached for their views and direction. Programs must respect Aboriginal culture and be presented to teens in their own language.

At the national level, the federal government could consider using the framework in national children's strategies, sponsoring outcomes research, communicating that public funds can be saved by investing in teen pregnancy prevention, and promoting economic opportunities for disadvantaged youth. The federal government could also develop resource materials, and support messaging through videos, popular theatre, and Internet sites. Investment for the implementation of the Canadian Guidelines for Sexual Health Education is needed for child care workers and teachers, as is reinvestment in public health educators.

The partners in this initiative hope this document stimulates discussion and action. They look forward to the next steps and hope the framework proves useful for moving ahead on the issue of teen pregnancy prevention.

A. INTRODUCTION

Why We're Taking Action on Teen Pregnancy

Each of the partners on this project was motivated by a common concern about the health, social, and economic consequences of the high rates of teen pregnancy in Canada. These consequences are felt by teen parents, their children and by society at large. The partners on this project had collaborated before, and each brought different perspectives to the issue. We believe that our differences have resulted in an approach to the issue that is both:

• informed by a national perspective aware of the potential power to link local, provincial, regional, territorial and national efforts, and
• grounded in a grass-roots, northern and native perspective, as well as a mainstream local urban perspective

Those of us who are concerned about teen pregnancy are not alone. Indeed, Health Canada's Community Action Program for Children (CAPC) and the Canada Prenatal Nutrition Program (CPNP) projects nation-wide identified teen pregnancy prevention as a priority for their communities.

We have been encouraged by steps taken in other countries where rates of teen pregnancy are high and believe that we can move forward on this issue in Canada.

The Partners in This Initiative

The Young/Single Parent Support Network

The Young/Single Parent Support Network (the Network) is a partnership of four agencies in the Ottawa area which target support services to pregnant teens, as well as to young/single parents and their children aged birth to five years - two vulnerable generations. Together, the agencies of the Network provide a continuum of services including a residential program, counseling, education, housing, support as well as training in parenting and child care, anger and stress management, and life skills.

Children of teenage parents are more likely to have problems and to eventually become teenage parents themselves, thus perpetuating the cycle of poverty begun by a teenage birth.
Linda Evans, "Sexual Health Education: a Literature Review on its Effectiveness at Reducing Unintended Pregnancy and STD Infection among Adolescents, " Proteen, Canadian Association for Adolescent Health, Montreal (1998).

The Network is often called upon to go into secondary schools to talk with teens about the realities of pregnancy and parenting. Responding to requests for these information sessions has been stopped temporarily because of concern that a growing group of adolescents seemed to become attracted to the idea of starting a family early. Rather than taking a prevention message from the talks, these youth were taking away the message - "there's help out here for you if you find yourself needing it". This may indicate that these youth are unable to find the help they need in the absence of pregnancy. This experience alerted the Network to the fact that as a society we are letting down a group of teens who don't feel they have much to lose by starting a family early. This was how the Network identified the need for an effective prevention strategy and a new educational message.

Eighty nine percent of CAPC/CPNP projects have rated the reduction of teen pregnancy rates as the most important or one of the most important things that can be done.
TPPP CAPC/CPNP survey.

The organizations of the Network collaboratively oversee two Health Canada funded projects - Brighter Futures for Children of Young Single Parents (a CAPC project), and Buns in the Oven (a CPNP project). The Network was the lead organization for this Framework for Action to Reduce the Rate of Teen Pregnancy initiative.

The Timmins Native Friendship Centre

The Timmins Native Friendship Centre islocated in a northern urban community thatis a magnet for youth from nativecommunities across the North. Some youthwho come to the Centre are away fromhome for the first time, and others are nativeyouth who have grown up in Timmins in apredominantly white environment. The Centre also works with Aboriginal youngparents and their children through its CAPC/CPNP programs.

In 1996, the rate of pregnancy among Aboriginal teens was four times the rate in non-Aboriginal youth.
Health Canada, A Second Diagnostic on the Health of First Nations and Inuit People in Canada (November 1999)

CAPC/CPNP projects operating in Aboriginal settings across Canada rated teen pregnancy as an important issue to tackle. Those who work with Aboriginal teen parents and their children have identified the need for more support for these young families at risk. The traditional support of the extended family is no longer something that Aboriginal youth can count on, so teen parents and their children are often without the help they need to thrive, particularly if they have moved to an urban setting.

The Canadian Institute of Child Health

For over 25 years, The Canadian Institute of Child Health (CICH) has acted as a dedicated voice for children and young people, improving their health and well-being. CICH's activities involve working with governments to make sure equitable policies are developed; working with professionals and educators to equip them with the best in research and programs; and reaching out to young people to give them information and programs that offer active participation, education and empowerment.

The Canadian Institute of Child Health is committed to improving conditions and initiatives in Canada so that every young person and every child, no matter what circumstances they're born into, can thrive. Every year, five out of every 100 Canadian teenage girls between the ages of 15 and 19 become pregnant. By comparison, the rates in many European countries is less than one out of every 100. These high rates of Canadian teen pregnancy along with the social and economic risks that accompany having a child at a young age prompted CICH to participate in anational prevention strategy. CICH also wanted to support those young people who have had (or will have) children at a young age and who are facing the task of adolescent development at the same time. CICH has consistently supported a life stages approach and strongly believes that creating optimal conditions for healthy child development across the country will improve the likelihood of positive health, social,and economic outcomes in later life.

The Second World-Wide Congress on Children concluded with three hopes:
1. that all children will survive and be nurtured
2. that all children will complete quality primary education
3. that all children will have an adolescence
As quoted by senator Landon Pearson, a Canadian delegate to the Congress.

Goals

The overall goal of this initiative was to contribute to the development of a framework for action for the reduction of teen pregnancy in Canada. The first specific goal was to learn more about what is being done and what needs to be done nationally to reduce teen pregnancy rates. Questions that were explored included: Why do teens become pregnant? What are the rates of teen pregnancy and by what factors do they vary? Who is doing what? Where is this work being done? What strategies and initiatives have been found to work, or not work? Is there a need for a national strategy; and if so, what would be the best approach? Who are the key stakeholders in the prevention of teen pregnancy?

The second specific goal was to explore what role CAPC/CPNP projects could take to reduce teen pregnancy in their communities, and to consider what strategies, tools, and resources would be needed.

The Methodology

The activities of this CAPC/CPNP national project were to:

• link with key stakeholders across the country
• survey CAPC/CPNP projects
• encourage creative thinking and action
• identify best practices, programs and resources, barriers and gaps
• lay the foundation for the development of a CAPC/CPNP- based coalition for the prevention of teen pregnancy, and
• make recommendations for future action

Four major pieces of research were conducted:

• a literature review (see Appendix A)
• a survey of 40 key informants (see Appendix B)
• five consultations involving 46 youth (see Appendix C)
• a survey of 756 CAPC/CPNP projects across Canada (see Appendix D)

In addition, the partners held three workshops; the first to plan for the research and the other two to digest and analyse the information that came out of the four research activities. During this process, consultations were held with representatives of government, CAPC/CPNP projects, and Aboriginal communities to expand thinking and critique the developing framework for action. ³ (see Appendix E)

Exhibit 1 provides an overview of our methodology and identifies the lead partner responsible for each research activity.

Caveats and Limitations

As in most research, a number of caveats and limitations must be mentioned.

• Despite tremendous efforts, there were major challenges to informing this work with Aboriginal content. There is little documentation about teen pregnancy and its prevention for both on- and off-reserve First Nations peoples. Similarly, there is little written about Inuit and Metis peoples and teen pregnancy. Also, the CAPC/CPNP survey was unable to capture the experience of reserve projects as they are supported by a different funding stream⁴ and consequently were outside the scope of this work. These weaknesses were addressed somewhat by the key informant interviews and consultations with representatives from national Aboriginal organizations. Nevertheless, the experience and voice of Aboriginal peoples is inadequately represented in this document.
• Key informants represented a broad cross-section of stakeholders. This initiative's research reflects excellent representation from non-government organizations, community programs and academic researchers. There was less representation from the education, religion, and media sectors.
• Although the research takes a broad approach in examining the problem of teen pregnancy from a national perspective, the focus for recommended action is situated primarily within the framework of Health Canada's CAPC/CPNP projects. This narrower focus was a condition of the CAPC/CPNP National Projects Fund.
• Lastly, teen pregnancy is not an easy issue to tackle. It is complex, multifaceted, and touches on very strongly held beliefs and intimate decisions. The broad approach taken in this research has served to set the stage for more comprehensive work and action

B. POTENTIAL CONSEQUENCES OF TEEN PREGNANCY

This section lists some of the consequences of teen pregnancy - for the teen, for the child, and for society.

• Although not "doomed" to a life of hardship, teenage parents are less likely to complete their education and are more likely to have limited career and economic opportunities. ⁵
• Homelessness is twice as likely by the age of 33 for teenage mothers than for older ones. ⁶
• For many young mothers, living alone in an apartment is an isolating experience when they are already isolated from their peers by being a parent. ⁷
• The development of parenting skills is a challenge for youth who "by-pass adolescence entirely and grow directly into parenthood" and within communities in which the extended family has broken down and there is no one to turn to for advice and support. ^{8 910}
• Women who first gave birth at ages 16 and younger are more likely to have a second child within the next two years than are young women who have had their first chiId ages 17-20. ¹¹
• Some obstetrical risks are greater for young pregnant women, such as anemia, toxaemia, eclampsia, hypertension, and prolonged and difficult labour. ^{12 13}
• The education level and ultimately the occupation and income level of men who have children during their teens may be adversely affected. This in turn has negative economic consequences for the economic well-being of their children. ¹⁴
• Teen mothers are more likely to be at psycho-social risk, have histories of childhood aggression and withdrawal, and transfer these risks and behaviours to their children. ¹⁵
• The pressures teen parents face predispose them to child abuse and neglect. ^{16 17}

• Babies of teenage mothers are at increased risk of pre-term birth, low birth weight and death during infancy. ^{18 19}
• The infant mortality rate for babies of teenage mothers in the first year of their lives is 60 per cent higher than for babies born of older mothers. ²⁰
• Children of teenage mothers are more likely to suffer early childhood injuries and acute illnesses - especially poisoning or burns - and twice as likely to be admitted to hospital as a result of an accident or gastro-enteritis. ^{21 22}
• Children of teen mothers are at higher risk of physical and mental health problems and social and academic difficulties - they are almost three times as likely to display conduct disorder than children who were born to mothers thirty years of age or older. ^{23 24}
• Children of young teen mothers are almost three times as likely to be behind bars at some point in their adolescence or early 20's as are the children of mothers who delayed childbearing. ²⁵
• The children of young teen mothers score lower in mathematics and reading recognition and in reading comprehension in the period up to age 14. These differences carry over into adolescence in the form of greater likelihood of repeating a grade and being rated unfavourably by teachers in high school. ²⁶
• There is poor take-up of breast-feeding among young Aboriginal mothers, and their poverty can prevent them from securing the foods they need. This is particularly a problem in remote communities. Substance use while pregnant and breast-feeding is also a problem. Aboriginals are opposed to fostering and adoption that disconnects Aboriginal children from their roots. ²

Young teen childbearing has significant consequences for the health and well-being of the children of teen parents. These consequences are costing the taxpayer and society enough to merit close policy attention. An individual child born to a teen mother is not necessarily pre-destined to poor outcomes. Although individual outcomes can vary, statistics show that children of teen mothers have a greater chance of consequences that carry a higher social cost: ²⁸

• higher risk of school drop out
• higher risk of involvement with the criminal justice system for parents and child
• increased likelihood of living below the poverty line
• more frequent child abuse and neglect, and
• increased number of children in car

C. SOME FACTS ABOUT TEEN PREGNANCY

This section outlines some basic facts about teen pregnancy and shows that, while Canada has made some headway on teen pregnancy rates over the past 30 years, it could do a lot better. There is evidence to suggest that the pay-off would be worth the investment.

We're Doing Better than We Did in the Seventies, but Worse than We Did in the Eighties

Statistics Canada reports that there were 46, 800 teenage pregnancies in 1994 compared to 61, 200 in 1974. However, since 1987, the teenage pregnancy rates have been increasing. ²⁹ Similarly teen births and abortions have rebounded from their recent respective lows, but are below their historic highs. This is especially true of teen births, which in 1995 were at 60% of the level of 20 years earlier.

Rates are Higher Among Aboriginal Teens

Data from the Atlantic provinces, the Prairies and British Columbia show 1997 teenage pregnancy rates in First Nations that were up to four times higher than the 1995 national rate.³⁰ The rate in younger First Nations adolescent girls (under the age of 15) was especially high, particularly on reserves, where it was about 18 times higher than in the general Canadian population (11.0 per 1000 live births, versus 0.6, respectively).

Teen Birth Rates are Four Times Higher Than Many in European Countries

Canada's teenage birth rate is six times that of Japan or Switzerland and more than twice that of Sweden and Finland. However, Canada's rate is significantly lower that the United States and somewhat lower than New Zealand.

Teen Pregnancy Prevention Saves Money

Research in the United States has found that "for every government dollar spent on family planning services, from $2.90 to $6.20 is saved as a result of averting expenditures on medical services, welfare and nutrition services. "³¹

We'd like to know more
There is little data about relative risk of teen pregnancy related to determinants of health such as poverty, cultural affiliation, rural/urban.

The Safe Sex/Contraceptive Message Isn't Getting Through to Everyone

• Health Canada's 1994/95 National Population Health Survey³², with a sample of nearly 2000 youth, found that:
  • 44% of males and 43% of females reported being sexually active between ages 15 and 19.
  • Thirteen percent of teen females and 21 % of teen males reported sex with at least two different partners in the previous year.
  • Among sexually active teens aged 15 - 19, 51 % of females reported having sex without a condom, compared with 29% of males.
• In a school-based survey conducted in Nova Scotia, approximately 61 % of Grade Twelve students (ages 17 to 18 years) reported having sexual intercourse in the year prior to the survey. Of those who were sexually active, only 32% always used condoms, and 40% indicated that they had had two or more partners in the past year.
• In 1996, girls aged 14-19 years had the highest rate of reported chlamydia and gonorrhea infections in Canada, indicating a breakdown of safe sex practices. ³⁴

D. PROFILES OF TEENS HAVING BABIES

Teens have different attitudes and predispositions towards pregnancy. This section identifies and describes the different predispositions.

Teens are Differently Pre-Disposed to Pregnancy

It can be useful to distinguish between teens with different pre-dispositions towards pregnancy because of their circumstances. Teens within the group we've called the "Oh No! Factor" teens have no intention of getting pregnant. When they realize they are pregnant they are distressed about the risk to their plans for the future and anxious about finding supportive help to navigate their choices. Another group we've called the "Disenfranchised - Nothing to Lose" teens may actually want to become pregnant. They see ways that the pregnancy can open doors for them, and tend to look forward to starting a family. Aboriginal teens form a third group. They face particular challenges because the traditional supports that were formerly part of their culture are no longer consistently there. The approaches to the prevention of teen pregnancy should be tailored to each of these three groups. It would be useful to know more about the percentage of pregnancies that are the result of different pre-dispositions.

While many young women have become pregnant unexpectedly, others have made the active choice to become pregnant, and some choose to become pregnant more than once.
Best Start - Algoma, Sexual Health Poster for Teenagers, 2000 http: //www. opc. ca/beststart/index. html.

The "Oh, No !" Factor

Canada is rated by the United Nations³⁵ as one of the best countries in the world in which to live, and most teens living in Canada can look forward to a relatively wide range of opportunities.

It is likely that a high number of teen pregnancies are the result of the "Oh,No! factor" - a breakdown in preparation for safe and protected sex on the part of a young woman and her partner. This is why there is so much emphasis on quality sex education and access to contraceptives in the literature on preventing teen pregnancy. It is known that the likelihood of pregnancy termination by abortion increases with educational attainment and favourable economic circumstances. ^{36 37}

"I got pregnant on the pill. We realize it's hard just to carry the child. But I was against abortion, so we kept the baby. So, we have a head on our shoulders. We'll take care of business."
A pregnant Francophone teen.

Disenfranchisement: Nothing to Lose

Research has shown that those teens who have low expectations of their own future have a higher risk of teenage pregnancy and often welcome the pregnancy as a way to bring meaning to their lives. ^{38 39 40} A minority of teens in Canada do not feel they have much of a future. Among this group, the rate of teen pregnancy is higher and the percentage of those pregnancies that result in teen parenting instead of abortion or adoption is higher.

Teens in this disenfranchised group often face a combination of circumstances associated with risk - low income, low expectations of their future, low self-esteem, alienation within family, sexual abuse, and poor parenting. The literature suggests that there is a correlation between young people who are substance users and smokers with those who become pregnant. ^{41 42 43 44 45 46 47}

Teen pregnancy is almost five times more common in the lowest compared to the highest income neighbourhoods.
Health Canada, "Sexual Risk Behaviours of Canadians, " HIV/AIDS Epi Update, LCDC (May 1999); Paula Stewart and Associates, "Population Health Approach to the Prevention of Teen Pregnancy", Research Evidence for Action in Forming a Canadian Coalition on the Prevention of Teenage Pregnancy: Three Background Papers, Young Single Parent Support Network (Ottawa: 1998).

"Adults think youth are irresponsible, yet, some young people started working at 13 years old, living in an apartment, managing. " "We do not feel adults let us live our youth. Time flies by so fast, we sometimes do not know how to benefit from life. "
From a focus group of Francophone pregnant teens.

"My baby really turned me around, and I've made big changes to my life because of her. People think young people do not have any directions, plans... all we do is think about the future. "
A Francophone teen parent.

Young women from low income families are getting pregnant at a higher rate than those from middle and upper income families. And poverty rates among youth living in large urban centres rose substantially between 1990 and 1995. ⁴⁸ Social researchers have noted a growing "underclass" in Canada - individuals who have less and less access to economic security and opportunity. The Canadian Council on Social Development also reports growing income disparities between the poorest and the richest in Canada.

Race and ethnicity seem to be less of a factor than social class. As one key informant noted "we know that black teen girls from middle class families are not getting pregnant more than their middle class white peers". ⁴⁹

"The fact that child-bearing is more common for teens in minority and disadvantaged groups has been documented in studies in the United States and United Kingdom. "
Susheela Singh and J. E. Darroch, "Adolescent Pregnancy and Childbearing: Levels and Trends in Developed Countries, " Family Planning Perspectives 32. 1 (2000): 14-23

Aboriginal Youth: Eroded Traditional Supports

Aboriginal youth have arate of teenage pregnancy four times higher than average. Aboriginal communities as a whole face circumstances which are disenfranchising. Aboriginal youth who live on reserve and have children are traditionally supported by their families. In families where that support is still intact, the baby often goes to live with the grandparents until the parent(s) is/are in a position to parent. Inurban settings, the extended family support is not there for Aboriginal teen parents and their children.

Aboriginals acknowledged the vigour with which adolescent parenthood is frowned upon in the country at large. However, they were unwilling to censor Aboriginal women who become pregnant at early ages. Noting that early onset of parenting was common in traditional Aboriginal societies, participants agreed it is the breakdown in traditional support structures and values rather than teenage parenting per se which is responsible for the health and social problems teenage parents and their families often face. "
Madeleine Dion Stout and Gregory D. Kipling, Aboriginal Roundtable on Sexual and Reproductive Health (Ottawa: Aboriginal Nurses Association of Canada, 1999).

E. FACTORS THAT CONTRIBUTE TO TEEN PREGNANCY

Each young woman who gets pregnant has a unique set of circumstances that contributed to the situation. However, key informants and experts generally cite certain factors as powerful contributors to the high rate of teenage pregnancy in Canada.

Need for Effective Sex Education: Knowledge, Practical Skills, and Free Contraception

Key informants surveyed in this initiative identified the lack of effective sex education and access to contraception as two of the most important contributors to Canada's high teen pregnancy rate. They stressed that youth need practical skills for negotiating relationships, and dealing with desire. They need accurate information about contraceptive options and about sexually transmitted infections (STIs). In many communities, particularly in rural areas, youth lack access to confidential information and free contraception.

Sex education is inconsistently provided across Canada. Key informants reported that although in many provinces the sex education curricula is good, it is very inconsistently delivered. Public health cut-backs have reduced the number of public health nurses providing sex education in many communities. Teachers and principals tend to stick to the biology of reproduction and shy away from practical issues around healthy sexuality, such as how to handle arousal or how to be intimate without risking pregnancy and STIs. ⁵⁰

"The use of contraception requires rather sophisticated skills - it is usually complicated, anxiety-provoking and awkward for teens who are far too uptight to plan for sex. "
An academic researcher in sexuality education.

"... many teachers reported that they do not cover topics such as sexual orientation, oral or anal sex, masturbation and pleasure/fulfilment. Also, most teachers use traditional teaching methods such as lectures, videos and large group discussions. Active learning strategies such as role-playing, student journals and small group discussions are used infrequently. "
Council of Ministers of Education., Canada (CMEC), Schools, Public Health, Sexuality and HIV: A Status Report, Executive Summary, (A study funded by the HIV/AIDS Prevention & Community Action Program, Health Canada, 1999) 4.

No Reason Not to Get Pregnant

Key informants also report that lack of opportunity and hope for the future is a driving force behind high rates of teen pregnancy in Canada. Throughout the developed world, teenage pregnancy is more common among young people who have been disadvantaged in childhood and have low expectations of education or the job market. ⁵¹ The literature shows that youth living in poverty have a teen pregnancy rate which is five times the average. ⁵² Socio-economic circumstances seem to play a major role in rates of teen pregnancy. There may be a growing "lost generation" of young people who see no reason not to get pregnant. For teens with few positive things going on in their lives, such as prospects of a job or further education, there is little cost to getting pregnant. For some disadvantaged youth, particularly for girls whose self-esteem tends to drop as they mature, sexuality is all they have of value.

Aboriginal key informants believe the high rate of teen pregnancy in their communities is caused by poverty and isolation and lack of effective sex education. They rate factors related to unhappy family of origin and self-esteem lower than mainstream key informants.
TPPP Key Informant Interviews.

"Not all teen pregnancies are accidental. In fact, many teen girls may view pregnancy positively. It can provide them with a role and a means of getting out of their parents' home. However they see only the short-term benefits, not the long-term consequences. "
An academic researcher.

Desire to "Re-Create" the Family

Dr. Alan King, a Queen's University researcher of trends in risk-taking behaviour among youth, suggests that alienation among young women is a key contributor to risk of pregnancy - and other risky behaviours such as tobacco use and substance abuse. This alienation results from a combination of conditions at home, in school and in the community. At home, there may be a lack of feeling loved or a sense of belonging. At school some incident or difficulty may turn a girl off from "the success stream". Alienated girls do not feel part of their community, even though they often feel very strongly about social issues. Teens who've been sexually abused and who've been involved with the child welfare system also are at higher risk of becoming pregnant as teens. These deficits in family life can contribute to a need for love and belonging and can lead alienated young girls to believe that having a baby of their own will fill the emotional gap and give them a place and purpose in life.

Mixed Messages

Media images and messages are full of seduction and place high value on sexual attraction and activity. At the same time, parents and school officials tend to be embarrassed or silent, keeping their fingers crossed that young people will be responsible. However, the net result of silence is not less sex, but less protected sex". ⁵³ In North America, compared with European countries, teens tend to see sex as associated with spontaneity and romance. Girls in particular are loathe to prepare for their first sexual encounter - preferring to appear to be "swept off their feet". Many key informants cited the prevalence of media messages around sexuality as a risk factor for vulnerable teens, especially those who lack self-confidence.

"Teens get double messages from the media: Be sexy but don't be actively sexual. "
A sex educator who was interviewed as a key informant.

F. TEEN PREGNANCY MYTHS

Myths can interfere with effective public policy and action on teen pregnancy prevention.

"Sex Education Promotes Sexual Activity."

There is a widespread belief that talking about sexuality with adolescents will "unleash" sexual behaviour. There are neither studies nor evidence to back this fear.¹

"Parents Oppose Sex Education in the Schools"

In a survey conducted by SIECCAN in 1996, 85% of parents agreed with the statement "Sexual health education should be provided in the schools."²

"Abstinence is the Answer"

While it's important to help teens develop the skills to negotiate abstinence, programs which are based solely on abstinence have been shown to be ineffective in reducing rates of teenage pregnancies unless they are augmented with contraception information and access.³

"Once a Teen Becomes a Parent, She and Her Child are Doomed to a Life of Hardship."

Many women who gave birth to children in their teens have made satisfactory lives for themselves and their children. Many children born to teen parents have thrived. However, statistics show teen parents are less likely to have a healthy birth, to have income security, and to access post-secondary education than those who postpone pregnancy.

" Teens Who Have Abortions Did Not Want to Get Pregnant, While Teens Who Keep the Baby Did Want to Get Pregnant"

People who work with teens and teen parents report that sometimes teens are not given full information and the freedom to choose what to do once they become pregnant. Some teens report feeling coerced into an abortion by their parents or professionals and spend the rest of their lives mourning for the child they never knew. Others report feeling coerced into having the baby.

G. PRINCIPLES GUIDING THE DEVELOPMENT OF A FRAMEWORK FOR REDUCING THE TEEN PREGNANCY RATE

Discussions among the participating partners, interviews with key informants, and consultations with Aboriginal, government, and CAPC/CPNP representatives helped to clarify the principles that should guide the framework for action.

The Framework Should Place Reducing the Rate of Teen Pregnancy in a Health Promotion Context

The overall goal of the framework is to maximize the number of children in Canada who are thriving, and the number of youth who are thriving and able to have their adolescence.

The early years of child development set the stage for learning behaviour that affects health throughout the life cycle. Strategies that use the determinants of healthy development to increase the health and well-being of all children and youth should help to reduce the negative circumstances surrounding children's lives.4 Programs that address teen pregnancy prevention in the context of healthy sexuality can be part of a broad strategy aimed at determinants of health. Furthermore, adolescent sexual behaviour must be placed within the broader picture of overall adolescent development.5 Youth have tremendous potential for developing life skills that will remain with them throughout their adult life. As a society, we have a responsibility to create conditions in which all teens can have opportunities for healthy personal development. Currently, Canada is failing a significant number of children and youth in this regard.

Health is defined as "the ability to realize aspirations and stisfy needs and cope with a changing environment".
Health and Welfare 1986. as quoted by paula Stewart and Associates. Population Health Approach to the Prevention of Teen Pregnancy: Research Evidence for Action in Forming a Canadian Coalition on the Prevention of Teenage Pregnancy: Three Background Papers, Young Single parent Support Network (Ottawa: 1998).

The Framework Should Use a Health Outcomes Approach to Address a Complex Set of Factors.

It is important to acknowledge the complexity of the issue of teen pregnancy. The phrase "determinants of health" refers to the large number of multi-layered and interactive factors that affect the health of an individual. The Canadian Federal, Provincial and Territorial Advisory Committee on Population Health divides determinants of health into five categories:

• personal health practices
• individual capacity and coping skills
• community institutions
• the social and economic environment
• the physical environment

An understanding of teen pregnancy through a health determinant lens is an effective tool for policy making, program development, and evaluation. Since each individual's experience of physical and emotional development is unique, these health determinants provide a way of analyzing health outcomes.

"The Platform for Action of the Fourth World Conference on Women compels us to develop better understanding of all the determinants of health which influence the development of girls and young women. After all, "the girl child is the woman of tomorrow."
United Nations 1995 as quoted by Jennifer Tipper. The Canadian Girl Child: Determinants of the Health and Wellbeing of Girls and Young Women (Ottawa: Canadian Institute of Child Health. 1997) 12.

The Framework Should Emphasize Healthy Sexuality

Healthy sexuality includes "knowledge of self; opportunities for healthy sexual development and sexual experience [and] the capacity for intimacy".⁶ The concept of healthy sexuality acknowledges that emotional, physical, and spiritual health are components of successful sexual health. Sexual health not only includes the knowledge of birth control and risk behaviours, but ways to negotiate difficult decisions about intercourse, abstinence, and sexual activity. Healthy sexuality depends on both informed individual self-direction and mutually protective collaboration between individuals.⁷

The inclusion of both male and female experience is vital. The literature review recognizes that teen pregnancy is directly tied to the different social expectations, ideals and behaviours that girls and boys are expected to follow.

The Framework Should Be Inclusive and Flexible

To allow for effective implementation, a framework must be able to be adapted by different cultural groups and communities. Aboriginal key informants were very clear that for their communities to buy in, social and health programs had to be designed by them. A framework has to allow for local communities to decide how to do things, otherwise it will not be accepted. Aboriginal people are less likely to go to programs that are not customized for them. Models will change even between Aboriginal communities that are ten miles apart. Likewise for CAPC/CPNP projects, the implementation of the framework will be different in different communities.

If sexuality lessons that promoted discussion of sex before marriage were to be put in the school, Muslim representatives would object to it because "dating is not allowed in our faith (and) we don't discuss birth control."
Key informant interview with a retired teacher and elder in the Muslim community.

"...Sex education at an early age... it has to be integrated into the school curriculum K-12 (and there) has to be parental involvement."
Key informant interview with an elder and principal of a First Nations high school in Manitoba.

The Framework Should Facilitate Coordinated Advice and Support

"What are we going to do for a whole group of young people who started out without equal opportunities that we like to believe people have?" asks Sorenson.⁸ The risks of teen pregnancy for the mother and her child and to a lesser extent for the father have been well documented. Overall, teen parents are likely to remain poorly educated, have additional unplanned pregnancies, experience broken relationships, endure long-term poverty and have children with emotional and behavioural problems. Research⁹ indicates that pregnant teenage girls with low educational aspirations and limited opportunities are more likely to decide to become parents. Many of these risks may be reduced with more coordination of support for vulnerable teens. Indeed the evaluations^{10 11} of federal initiatives such as the Child Development Initiative which includes the CAPC and CPNP programs targeting families in very disadvantaged circumstances indicate positive impacts. Evaluations of local projects^{12 13} show improvement in the lives of mothers and children who remain connected to local community supports. In other words, youth who are receiving services are more likely to do better.

The Framework Should Address the Needs of Young Males

Research¹⁴ has shown that young fathers often want to stay in touch with their children and play a proper part in their upbringing. Yet, there are few if any established networks for young father groups in Canada. Presently, a fathering initiative funded by Health Canada's CAPC/CPNP National Projects Fund is being conducted to explore this issue.

In general, young fathers are understudied, under serviced, and commonly unidentified. They are typically excluded from the adolescent family. In Canada we collect statistics on teen pregnancies, but have little data on teen fathers.¹⁵

"We need more guys in the field. Young men tend to be more difficult to get talking, hard to connect with."
Community program key informant.

"We socialize our young men to feel they are entitled, and our young women to accommodate."
Key informant interview with front-line sexual health specialist.

Part of the difficulty in acknowledging the teen father as an important member of the family has to do with how fathers are considered in society generally. The typical male role is seen as that of provider and protector. Teen fathers have difficulty filling either of these roles. They may not have finished high school and may only be able to find lowpaying jobs. They may not be living with the mother of their child.16 Parenting has culturally been defined as women's work and men are typically considered incapable of caring for infants. In some cases, teen fathers are excluded from decision-making around the pregnancy or parenting. They have been stereotyped as violent or irresponsible, and have been left out of policies directed at families. This is slowly beginning to change, but more advocacy is needed to focus on the role of the teen father and the supports he needs.¹⁷

The Framework Should Encourage a Community-Based Approach

Almost everyone consulted as part of this initiative recommended a community-based approach to ensure buy-in. There are many local organizations providing health, social and educational services that have a mandate to reduce teen pregnancies and to support pregnant and parenting teens. It is important to recognize these endeavours and to capitalize on the their strengths. Better still is an approach that would harness all this activity and co-ordinate it towards a common goal.¹⁸ Indeed partnerships and collaboration between organizations within communities is a guiding principle of the federally funded CAPC and CPNP and Aboriginal Head Start programs.

The Framework Should Involve Youth in Program Policy Design and Implementation

Consultations with both young women and young men must be a priority in the development of a framework for action and its implementation. This is necessary for maintaining relevancy to real lives lived and perceptions of young people in diverse communities, cultures and socio-economic circumstances. To ensure that youth can and do participate in programs, action plans and policy development, it is important to recognize and overcome the barriers that might reduce or discourage their participation.¹⁹

Existing studies ... paint a picture of a diverse teen population. W hile there has been great emphasis on the proportion of teens who have sexual intercourse, it is important to note that many are delaying sexual intercourse. There is increasing sexual intercourse with increasing age and an associated increase in number of partners. There is inconsistent use of contraception. Street youth have almost all had sexual intercourse and many have had several partners.
Paula Stewart and Associates, "Population Health Approach to the Prevention of Teen Pregnancy", Research Evidence for Action in Forming a Canadian Coalition on the Prevention of Teenage Pregnancy: Three Background Papers, Young Single Parent Support Network (Ottawa: 1998).

H. A FRAMEWORK TO REDUCE THE TEEN PREGNANCY RATE BASED ON EVIDENCE OF WHAT WORKS

This section outlines a Framework for Action that includes three spheres of action and is based on best practice literature, the valuable input from key informants and from the survey of CAPC/CPNP programs.

The Framework

Figure 1 presents the three spheres of action that comprise the Framework to reduce teen pregnancy rates in Canada - Pro-Action, Postponement, and Preparation/Support. The overall goal of the framework is to maximize the number of children in Canada who are thriving, and the number of youth who are thriving and able to have their adolescence. Reduction of the rate of teen pregnancies is one of the key indicators of the degree to which this goal is being reached.

Pro-Action: Having a Reason to Postpone Pregnancy

The goal of the Pro-action sphere of action is to reduce the percentage of teens who see having a baby as a doorway to love, belonging and opportunity. As a society, we have a responsibility to create conditions in which all teens can have a safe, healthy adolescence and opportunities for healthy personal development. Currently, Canada is failing a significant number of children and youth in this regard.²⁰ Research has identified an alienated cluster of youth who are lost along the way - they don't feel a part of family, school or community. Lack of options and opportunities for positive engagement and experiences of success in family, school, community and society can either exacerbate risk or contribute to building resilience.^{21 22} It's between the ages of ten to fourteen when young people begin to show signs of alienation.

Pro-action strategies are aimed at building resilience in children and youth who are disadvantaged. There is a growing body of evidence about ways to do this by working with children, their families, and their communities. Researchers²³ have noted a variety of factors which can reduce the consequences of teen pregnancy for parent, child, and society including:²⁴

• personal characteristics such as social competence, problem-solving ability, autonomy, perseverence and an optimistic outlook
• coping skills in families
• families and schools that establish high but achievable expectations along with opportunities for children to participate and contribute
• communities that support the family and see children as a shared and precious resource

According to several participants in the Aboriginal Roundtable on Sexual and Reproductive Health, sex education cannot be conducted effectively so long as tools and resources are inappropriate in terms of language and culture. As one public health nurse from a remote community stated, teenagers always ask why there're only "w hite" in her videos and pamphlets. Information about various family planning methods was also deemed to be of inferior quality, as were the ways of involving men, so they too could be educated about their responsibilities... Several participants criticized programs which tend to consider sexuality apart from the wider [. . .] spiritual context.
Madeleine Dion Stout and Gregory D. Kipling, Aboriginal Roundtable on Sexual and Reproductive Health (Ottawa: Aboriginal Nurses Association of Canada, 1999).

Unfortunately, the erosion of social programs in Canada has led to a reduction in resilience-building programs. In some provinces, there has been cuts to welfare rates. Many school boards have cut programs for special needs children. User fees have blocked access to recreation and community resources such as museums. There are longer waiting lists for family support programs. Universities and colleges have raised rates of tuition.

More effective pro-action strategies can be expected to build resilience in disenfranchised youth, to open doors to options other than early parenting, and to help reduce the risks for children born to teen parents.

Postponement: Having the Know-How to Postpone

The goal of the postponement component of the framework is to support all teens to postpone pregnancy - until they are in a position to optimize opportunities for themselves and their prospective child - by reducing the rate of unprotected intercourse by all adolescent young women and their partners. Effective sex education and confidential access to free contraceptives are the key strategies of this sphere of action.

"Sex Ed class does not teach much. They talked about how to put a condom on, the biological level, but often too late, people were already doing stuff. They don't talk about what happens before and after."
A pregnant Francophone teen.

Sex education was introduced into Canada's schools in the late 1940's and early 1950's.²⁵ In 1969 an amendment to the Canadian Criminal Code made it legal to sell and distribute contraceptives and information about them. Although health education (where it has existed at all) has often focussed on abstaining from sexual behaviour, it has since then also included information on the use of birth control methods.

In 1988, a Supreme Court of Canada decision made abortion neither legal nor illegal. In the last ten years, spurred on by the HIV/AIDS epidemic, there has been greater public support for including sex education in the school system.²⁶

In 1996, 85% of parents who responded agreed with the statement "Sexual health education should be provided in the schools." SIECCAN, 1996, as reported by Alex MacKay in Key Informant Interview. Mr. MacKay is Research Coordinator and Editor of the Canadian Journal of Human Sexuality of Sex Information and Education Council of Canada (SIECCAN), located in Toronto."Adolescents rated their school as their preferred source of sexual health information out of a choice of six possible sources."
MacKay and Holloway as reported by Linda Evans, "Sexual Health Education: a Literature Review on its Effectiveness at Reducing Unintended Pregnancy and STD Infection among Adolescents," Proteen, Canadian Association for Adolescent Health, Montreal (1998).

In 1997-98, the first study was conducted on the status of policies, programs and practices in the school systems and public health systems across Canada that seek to prevent the transmission of HIV/AIDS and to promote the sexual health of adolescents.²⁷

Preparation and Support: Having a Solid Foundation

The Preparation and Support component of the framework is concerned with building the psychosocial foundation of the individual. It begins at birth and even before. There is evidence to suggest, in recent studies of the neurological system,28 that early developmental supports have a great deal to do with the later development of self-esteem, and a sense of secure belonging and attachment. Psycho-social factors that are developed from the earliest age affect self-esteem, body image, and goals and decision-making.

With respect to reducing the rates of teen pregnancy, there are two generations to target for preparation and support. The first is the children who are in circumstances which pre-dispose them to high rates of teen pregnancy due to disenfranchisement. The second is the teen parents themselves. It is essential to ensure that children have the best start they can have. No matter how successful any teen pregnancy reduction campaign, there will still be teens who become parents. There is evidence to suggest that resilience-building supports and preparation for childbirth and parenting can make a difference to the teen and, as importantly, to the teen's child. Interventions in "Preparation and Support" sphere of action should be geared to families experiencing stress, including teen parent families. The objective is to support the development of resilience and thus to reduce the risk that the next generation will perpetuate the cycle of teen pregnancy because of psycho-social needs.

The goal of the "Preparation and Support" component of the framework is to support those teens who do become pregnant and become parents:

• to postpone any subsequent pregnancies,
• to maximize their own healthy development through the rest of their teen years
• to maximize their child's healthy development through his or her early years, and
• to reduce the probability that the child will also become a teen parent

Action would involve providing the parent(s) with the basics they need to ensure safety, nutrition, and healthy development and support them through the transition into parenthood. "Pro-action" strategies which are specially targetted to teen parents and their children can complement "Preparation and Support" strategies.

Strategies for supporting teen parents and their children will differ based on the community and culture of the parent and child. Strategies within Aboriginal communities are more likely to focus on helping the extended family support teen parents and their children and re-building traditional supports around the family and community. Strategies with a group of teen parents who did not receive nurturing parenting themselves may focus on the development of positive parenting skills, reassurance, the development of relaxed caring for baby, and understanding early child development.

What doesn't work:
- scare tactics, and
- isolating high risk kids from mainstream for "special interventions"
Joy G. Dryfoos, "Common Components of Successful Interventions with High-Risk Youth" Adolescent Risk Taking, eds. Nancy J. Bell and R. W. Bell (London: Sage Publications, 1993) 131-147.

Strategies Shown to Work

Pro-Active Strategies

The National Crime Prevention Council²⁹ mentions several protective factors that reduce the effects of risk and thus lowers the chances that a youth will develop serious anti-social problems. Some examples of protective factors are problem-solving, life and communication skills; sociability; resilient personality or temperament; a sense of belonging; secure attachments to positive parent(s) or family; positive relations with "prosocial" peers; access to other caring and supportive adults; appropriate discipline, limit-setting and structure from parents; and opportunities to experience success and build self-esteem.

The New York City Children's Aid Society claims to have reduced teenage pregnancy rates among high risk youth from 14% to 4%. They combine several approaches:
- employment and continuing education opportunities
- self-esteem through recreation and arts programs
- individual counselling and problem-solving intervention.
Metta Winter. "Teenage Pregnancy Prevention Programs that Work" Cornell Cooperative Extension, Extension News Service (1997).

Dryfoos^{30 31 32} has done extensive reviews of the literature on adolescent risk-taking. For best results in risk reduction, she recommends approaches that combine individual-based interventions with school-based and community-based ones. Those which have been shown to be promising include:

Individual:

• individual attention in dealing with peer influences and job readiness (mentors, counselors, case managers)
• experiential skill development
• home visiting with family in early childhood and pre-adolescence

School-Based Interventions:

• alternative schools, special education, teacher training, effective roles for parents within the school
• on-site counseling and mentoring, health services, opportunity advancement, community mental health programs

Community-Based Interventions

• education and media campaigns
• access to contraception, jobs, recreation, further education
• action on homelessness, poverty, racism, employment, welfare

A culturally appropriate approach which is owned by the community should be used within Aboriginal communities. The approach should take into account the following factors³³:

• Aboriginal people have serious objections to the adoption or fostering of their children by non-Aboriginal families. The practice poses a serious risk to the vitality of their culture and language
• The breakdown of the extended Aboriginal family has resulted in increased risk for teenage parents and their children. Because children have become increasingly disconnected from grand-parents, aunts and uncles, lack of positive role models places them at heightened risk of falling into a pattern of self-destructive behaviour
• Older generations must make strong and sincere efforts to work with young people's energy and interests, especially when they make decisions that affect them
• Inter-generational conflict has become increasingly pronounced in many Aboriginal communities, and has led to such problems as alienation, substance abuse and early onset of sexual activity. Grandparents and elders are being excluded from the child-rearing process, resulting in a loss of language and traditional knowledge on the part of the younger generation

Postponement Strategies

Studies have shown that sex education is most effective if:

• it is combined with free, confidential access to contraceptives (some Canadian jurisdictions have adolescent health clinics staffed by primary care workers in or near schools)
• healthy sexuality is part of the curriculum from kindergarten onwards
• healthy sexuality includes interactive experiential skill-building developed through selfdiscovery and practice techniques such as role-playing34 - curricula provided in didactic format without skill development has been shown to be ineffective³⁵
• the following topics are included: negotiating agreements, relationship development, communication, decision-making, goal-setting, body image, dealing with sensations and feelings, use of contraceptives, masturbation, sexual preferences, and alternatives to intercourse
• it aims to help students postpone first intercourse, and use contraceptives/condoms when they do become sexually active - approaches that advocate only abstinence have been shown to be ineffective³⁶
• skill development related to sexuality is provided by an outside resource person who is an experienced sex educator and credible to students - although public health nurses have been shown to be effective providers of school-based sex education, cutbacks to public health across the country have significantly undermined the capacity of public health departments to provide sex education^{37 38}
• parents are oriented to what students are learning, reinforce the messages, and are comfortable talking with their children about sexual health issues from a young age
• HIV/AIDS risk-reduction education combines information, motivational opportunities, and skill-building experiences³⁹ - this approach has also been shown to be effective in pregnancy prevention among adolescents⁴⁰ and has formed the basis of policy documents such as the Canadian Guidelines for Sexual Health and Education in Canada⁴¹

Youth need to know the difference between like, love, and lust if they are going to m ake responsible decisions about their sexual health and their futures. Adults need to talk with youth about negotiating relationships and about sexual communication.
A 16 year old teen, Ottawa.

The Aboriginal Roundtable on Sexual and Reproductive Health recommends in addition the following approach for Aboriginal sex education:

• programs must be culturally appropriate, and must encompass a holistic human sexuality
• parents need to be included in education initiatives so that they can communicate openly and honestly about their children's sexual development
• family planning resources must be readily available
• resources must be culturally appropriate and of high quality
• community members must be informed about the benefits and risks of various family planning methods

Preparation and Support Strategies

Teenage parents who already have one child are at high risk of additional pregnancies during their teenage years. A number of programs have been shown to be effective in reducing repeat teen pregnancies and in decreasing the likelihood that the children of teen parents will be teen parents themselves. These include:

• home visiting programs that build parenting skills and provide counseling regarding contraception and other issues - such as the Healthy Babies/Healthy Children program in Ontario
• enriched child development programs that involve the parent and demonstrate effective positive parenting - such as Head Start, or the Early Years' Centres recommended by McCain and Mustard.⁴²
• programs that offer prenatal nutrition, life skills, pre- and post-natal preparation, readiness for child birth, parenting and skill development - such as many CAPC/CPNP initiatives
• neighbourhood-based models that provide professional intervention and also promote mutual support and healthy conditions for families within a neighbourhood - such as Better Beginnings Better Futures programs in Ontario or the National Longitudinal Survey on Children and Youth demonstration sites projects

"Teenage pregnancy is not as hard as what society projects. They say that to scare youth. Before it was normal to have children young. In other cultures, it is also normal for teenagers to bear children. W hen I found out I was pregnant, I was very happy. Society tends to want to spoil that happiness."
A group of Francophone teen mothers.

"Many young women want to get pregnant to ensure that they keep their boyfriend, improve their financial situation, and put responsibility of child-rearing on the father. Relationship with the biological mother often becomes strained, very often resulting in separation."
A group of young fathers aged 18 - 24.

National Approaches

Sweden and Netherlands

What has enabled countries such as Sweden and the Netherlands to keep their teen pregnancy rates consistently down? Sweden and the Netherlands attribute their lower rates primarily to what we'd call "postponement" strategies.^{43 44 45} These include:

• sex education
• open discussion of human sexuality in the mass media
• easy access to contraception
• the active participation of both parents and teenagers in education programs

Other conditions exist in Sweden and the Netherlands which wouldn't necessarily be seen as oriented to teen pregnancy prevention but which help create conditions in which youth and children can thrive and choose options other than pregnancy.

England

Based on a thorough examination of teenage pregnancy by the Social Exclusion Unit⁴⁶, England has embarked on a comprehensive program of action with two main goals:

• reducing the rate of teenage conception, particularly among under-18s by 2010.
• getting more teenage parents into education, training or employment, to reduce their risk of long term social exclusion.

The action for achieving these goals falls into four categories:

• A national campaign, involving Government, media, voluntary sector and others to improve understanding and change behaviour.
• New mechanisms to co-ordinate action at both the national and local levels to ensure that the strategy is on track.
• Better prevention of the causes of teenage pregnancy, including better education in and out of the school, access to contraception, and targeting of at-risk groups, with a new focus on reaching young men, who are half the solution, yet who have often been overlooked in past attempts to tackle this issue.
• Better support for pregnant teenagers and teenage parents, with a new focus on returning to education with child care to help, avoiding solitary tendencies for under-18 lone parents, and pilots around the country providing intensive support for parents and child.

This comprehensive action plan is a ten year program to improve the climate in which young people prepare for adulthood, and the support for teenage parents and their children. Resources for the program have been found from within existing departmental programs for the period up to 2002. A package of around 60 million pound has been identified. Decisions about funding beyond this date will be made as part of the next funding review. Evaluation of impacts will be ongoing although it is too early yet for outcome reports.

The United States

The United States of America has one of the highest rates of teen pregnancy in the world. The U.S. government asserts that strong efforts are needed, particularly since teen parents face"tremendous challenges".⁴⁷ Prevention programs in the United States range from school-based education on risk behaviours to the creation of 'second chance' homes for teens with babies, to abstinence-only approaches.

One of the most successful initiatives in preventing teen pregnancies in the U.S. is an organized, well-funded, national strategy formed in 1995. The National Campaign to Prevent Teen Pregnancy works with many sectors of American society. Its goal is to reduce the teen pregnancy rate by one-third between 1996 and 2005. Its mission is to improve the life prospects of this generation and the next by reducing child poverty. Its five-pronged strategy includes the following goals:

• Take a strong stand against teen pregnancy and attract new resources and powerful voices to the issue.
• Enlist the help of the media
• Support and stimulate state and local action
• Lead a national discussion on the role of religion, culture, and public values in an effort to build common ground.
• Make sure that local community efforts are based on the best information available.

According to the National Campaign, "the national teen birth rate declined 3 percent between 1998 and 1999, reaching the lowest rate ever recorded."⁴⁸

The United States also has a number of organizations that have large corporate sponsors or receive money and support from faith organizations. One of the most well-known teen pregnancy slogans is "Not me, Not now".⁴⁹ A substantial number of organizations use an abstinence approach. The effectiveness of each organization's approach is not known.

I. KEY PLAYERS IN CANADA

There are players already working effectively across the country, taking great care to develop programs geared to the needs of their local communities. Whatever is done to further reduce the rate of teen pregnancy in Canada needs to build upon the work already being done in schools, public health departments, faith communities, community centres, and families.⁵⁰

The key informants interviewed for this initiative are key players. They were identified as leaders in Canada in the Aboriginal and non-Aboriginal communities with knowledge, experience and influence relevant to reducing the rate of teenage pregnancies.51 These individuals represent different stakeholder groups including researchers, community programs, sex educators, youth, non-governmental organizations, ethno-cultural groups, health, government, politicians, religion, and media.

Almost all key informants interviewed indicated that they would be interested in working toward the development of a national strategy or coalition for the prevention of teenage pregnancies. Some asked to know more. Many suggested names of individuals who would be effective champions. The main caveat to involvement was the desire for a community-based approach rather than a top-down approach. Key informants thought that reducing the rate of teenage pregnancy was an important societal goal that required coordinated and concerted action.

J. THE UNIQUE ROLE THAT CAPC/CPNP PROJECTS CAN PLAY

Characteristics of CAPC/CPNP Projects

CAPC/CPNP projects are in a unique position to facilitate action on reducing the rate of teen pregnancy. These projects are already working with young teen parents and are connected to valuable networks in their communities. Although their present focus is the "Preparation/Support" sphere of action (helping teens who are pregnant and parenting), they are already positioned by their contact with high-risk teens and adolescent-serving organizations to act as catalysts for new action on the other two spheres of action - "Pro-Action" and "Postponement". CAPC/CPNP projects:

• are managed by organizations that are part of grass-roots networks in communities across Canada
• are influential in their own communities, and are part of coalitions which extend into child care organizations, health services, social services, education, employment, cultural communities, recreational organizations, faith communities, and more
• are innovative, flexible, experienced in program development, community development, implementation and evaluation
• are linked to one another across their regions, and are supported by a collaborative federal/provincial infrastructure
• understand the determinants of health approach
• work with teen parents and their children and see the consequences of teen pregnancy on a day to day basis
• work with teen parents who are at high risk of further pregnancies
• have established a range of intervention models based on respect for cultural and geographic differences across Canada
• are linked with the National Children's Agenda

The survey of CAPC/CPNP projects revealed that:

• almost 90% of CAPC/CPNP projects rate the reduction of teen pregnancy as important or one of the most important things that can be done
• Aboriginal CAPC/CPNP projects (all of which are off-reserve) placed a high priority on reducing the rate of teen pregnancy
• 39% of CAPC/CPNP projects are active in reducing

How do CAPC/CPNP Program s Deal with Controversy around Sexuality and Abortion?
Some CAPC/CPNP programs are sponsored by faith communities with clear positions on abortion. They say "W e receive funding from the Catholic community so we must ensure we make referrals to agencies that include those that support the sanctity of life philosophy".

Examples of What CAPC/CPNP Programs are Already Doing

Healthy Babies, Bonnyville Health Unit

The Healthy Babies program run by the Bonnyville Health Unit in Bonnyville Alberta works to prevent further pregnancies with clients of its prenatal nutrition program by providing assistance with the purchase of birth control and counseling around contraception and sexuality. Outreach workers make special efforts to involve boys and men. One of the most successful messages they give to young men is: "The cost of child support for 18 years at approximately $300 per month is $64,800 - or the equivalent of 3 cars or 1 house."

The Healthy Babies program and the Lakeland Regional Health Authority commissioned a teen pregnancy research report52 that led to the development of a Teen Pregnancy Steering Committee.

Timmins Native Friendship Centre and Community

The Timmins Native Friendship Centre and the larger community offers a number of programs for youth which collectively form a strategy for prevention of teen pregnancy and the provision of support for pregnant and parenting teens. The Timmins Native Friendship Centre's CAPC/CPNP project offers sexuality workshops for pregnant and parenting teens covering topics such as healthy sex, contraception and the cost of raising a child. The Timmins Native Friendship Centre's Youth Coordinator focusses on providing recreational programs and holds monthly evening workshops for youth on healthy lifestyles. Subjects covered include:

• AIDS awareness
• healthy relationships
• respect for each other
• healthy sexuality
• use of tobacco
• traditional teachings on child rearing

The Timmins Womens' Centre runs a parents group entitled, "Safe Sex Safe Run Campaign". The Misiway Clinic, a primary health care centre, during one-on-one counselling sessions with individual youth may promote postponement and chastity, discuss contraception and provide condoms. The Porcupine Health Unit offers workshops for parents to help them talk to their teens about sex and healthy relationships. The O'Gorman Intermediate School provides sexuality education and some self-esteem development for preteen and teenage girls.

Young Fathers' Program

The Young/Single Parent Support Network of Ottawa-Carleton oversees the Young Fathers' Program initially established in 1997 by the Youville Centre. The Program provides flexible, accessible services, and advocacy to at-risk young fathers aged 16-25 and supports them in their efforts to live in a healthy family and community environment.

In weekly three hour sessions it offers:

• recreational activities such as basketball, floor hockey and outings
• group talks and guest speakers on child care, violence, relationships, family issues and custody issues
• life skills development in job searching, budgeting and education
• pizza and pop
• child care and transportation assistance
• individual counselling on issues such as anger management, parenting support and education, crisis intervention, shelter and housing help, healthy relationships, and custody

The development of a pro-active, local fathering network is also being actively pursued by the Program.

An all male staffing complement facilitates discussion of male issues, fathering roles and male feelings. The qualities the program strives to build upon with participants are:

• strong sense of what a father does
• confidence in parenting
• knowledge of good decision-making skills
• ways of coping with growing children
• strategies for dealing with conflict
• understanding of financial needs, and ability to find help in the community.

K. RECOMMENDATIONS FOR CAPC/CPNP ACTION

Levels of Intervention

Every community is unique, with strengths, resources and priorities that have developed over time. Some communities will want to focus their efforts on supporting those youth who are pregnant to help them and their children thrive. Others will want to give priority to providing children and youth with skills around the postponement of pregnancy. For others, the place to put more effort will be in giving youth reasons not to start a family early.

CAPC/CPNP projects are uniquely positioned to play a catalyst role in their communities. It is recommended that CAPC/CPNP projects take a leadership role in bringing concerned people together and developing a plan of action around teen pregnancy that fits their local needs, priorities, and circumstances. The list of options provided here can be a starting point for discussion.

This section is organized according to the level at which the intervention would occur, starting with mainstream local communities, moving on to Aboriginal local communities, and finally including some options for national, provincial and territorial action. Under each level of intervention, options are listed according to the action spheres of the framework - Pro-Action, Postponement, and Preparation/Support.

Principles for Action

• focus on the well being of children and adolescents
• involve youth in leading the effort and in delivering it
• allow Aboriginal people to customize their own programs
• give Aboriginal youth a substantive role
• bring programs to where youth are already meeting
• work with and strengthen existing supports

First Steps

• recruit support for action on teen pregnancy before any action plan is decided.
• hold one-on-one meetings with leaders from key sectors.
• find out what they know about teen pregnancy in the community, whether they are interested in working together, and whether they're in a position to take a lead role.
• hold a community meeting of interested people and provide information you've collected
• use this framework to brainstorm what could be done in your area.
• develop an action plan to move forward on a few key and achievable areas.

Action at the Mainstream Local Community Level

These are examples of successful actions which communities could consider to address teen pregnancy issues.

"Sex education is often delivered in a very technical way that doesn't engage youth to learn and ask questions ... (to learn negotiation skills) teens (both boys and girls) need role plays and interactive education to learn to say "not now" or"not ready for this" or "not that way".
Sex educator.

Pro-Action

Pro-action strategies will generally be focused on changing community conditions and opportunities. Often they are targeted at neighbourhoods with high rates of teen pregnancy and other indicators of adolescent risk. These strategies may be aimed at youth or children and intended to build resilience. Options that may be considered are:

• build the self-esteem of girls and boys age six and older
• develop curricula that helps build girls' and boys' self-esteem
• develop parent education which takes gender differences into account
• develop accessible arts and recreational opportunities for at risk families
• outreach to disadvantaged families
• develop a range of options for success within the educational system for those who are now becoming alienated and dropping out or are minimally participating
• develop after-school activities and summer activities for youth aged 11 to 16 - a particularly high risk age for youth
• build leadership skills among youth aged 11 to 16
• develop mentoring for at-risk children, youth, and families
• strengthen voluntary groups which can work to support families and youth

Postponement

Postponement strategies are generally aimed at building skills and access to services which will postpone pregnancy. Strategies may include:

• support parents and child care providers to teach and model healthy relationships and body image
• develop a parent/youth group to evaluate current sex education in schools and lobby for proven approaches
• advocate for access to free contraceptives and decision-making counseling for teens
• develop role models, mentoring and peer education for reaching young men with messages around date rape, AIDS prevention and contraception
• outreach to young men (including those in early twenties) through detention centres, employment centres, bars, clubs, sports leagues, colleges and universities

Preparation and Support

Preparation and Support strategies are aimed at helping young parents and their children to thrive and prevent teen pregnancy in the next generation. Examples of strategies for this group include:

• access to basic needs such as food, clothing, shelter, and safety
• access to prenatal care and breastfeeding support
• parenting skill development
• encouragement for thinking about future opportunities
• mutual support peer groups
• encouragement of connections to spirituality
• strengthening a sense of belonging
• messages about healthy body image and healthy relationships
• life skills, e.g., education, job searching, budgetting, and managing stress and anger
• coaching for significant family relatives and friends to be consistent, loving adults
• involvement of youth in planning committees
• safe places for youth to obtain information
• home visiting nurses
• free contraception
• priority access to substance abuse treatment for pregnant women

"It's not easy for teens in rural communities to access contraception where everyone knows everyone else's business. A lot of teens would rather get pregnant than buy a condom at the local pharmacy."
A manager of a community-based CAPC/CPNP program.

Action at the Aboriginal Local Community Level

It is essential for Aboriginals to have ownership and control over initiatives and services in their communities. Programs should reflect Aboriginal culture and traditions. Any CAPC/CPNP project aimed at action on teen pregnancy in Aboriginal communities should first approach elders and community leaders to discuss the issue and get their direction, then adapt the framework accordingly. Key informants from national Aboriginal organizations indicate that they thought the framework would be useful in thinking about options for action in their communities. They thought priority would probably be given to the Preparation and Support area to begin with.

Pro-Action

Pro-active initiatives to help aboriginal teens and children thrive include:

• school and health authorities working together
• employment preparation
• recreation and employment opportunities
• culturally-appropriate positive role models
• support for Aboriginal youth away from home for the first time
• cultural sensitivity training for anyone working with Aboriginal youth

Postponement

Aboriginal key informants felt that First-Nations-oriented health programs and early effective and culturally appropriate sex education would be the most helpful initiatives for reducing teen pregnancy.

Programs should to be adapted to native teens and presented in their own language. More education is needed on safe sex practices and HIV/AIDS prevention. It should be integrated into the school curriculum at all ages and parents and elders should be involved.

"Any programs designed to benefit Aboriginal youth are best dealt with by Aboriginal people - but we can share and use information from nonnative groups."
An Aboriginal key informant.

Preparation and Support

The Aboriginal Roundtable recommends the following actions for supporting Aboriginal teen parents and their children:⁵³

• innovative breast-feeding, nutrition and parenting programs
• safeguarding the supply and quality of country foods consumed by expectant or breastfeeding mothers
• culturally-appropriate programs to promote abstinence from alcohol and other drugs while pregnant or breast-feeding
• increased access to family planning resources, day care, and vocational training opportunities
• more reproductive and sexual health programs targeted to Aboriginal people living in urban areas
• better coordination of services

Action at the Provincial, Territorial and Federal Level

Pro-Action

It is recommended that the federal government, provinces and territories consider the following initiatives:

• using this framework within the National Children's Agenda
• supporting the development of the Assembly of First Nations Comprehensive Children's Health Strategy
• sponsoring outcomes research on reducing the rate of teen pregnancies using this framework
• communicating that public funds can be saved by investing in this strategy
• developing job readiness and job creation strategies to increase opportunities for disadvantaged youth

Postponement

• resource materials based on evidence and best practices
• marketing messages about how communities can benefit by reducing teen pregnancy
• marketing messages aimed at boys and young men that combat male myths
• a marketing campaign that uses an effective spokesperson and acknowledges healthy sexuality
• videos and popular theatre interventions to spark interest among youth
• Internet sites and links that will give young people access to information and support regarding sexuality
• review of healthy sexuality curricula guidelines required by Ministries of Education to ensure it meets effectiveness criteria set out in Health Canada's Sexuality Education Guidelines
• annual training for child care workers and teachers on healthy sexuality curricula
• reinvesting in public health educators and contraceptive access through youth clinics

Preparation and Support

• providing support for CAPC/CPNP programs to revise existing resource material to integrate information on healthy sexuality
• developing practical programs to support teen parents that include housing, nutrition, birth preparation, respite child care, home support for healthy parenting, education and job readiness training, and other resilience-building programs aimed at children of teen parents.

L. NATIONAL LEVEL OPTIONS

A National Strategy for Action in Canada

Although this research initiative was not aimed specifically at the national level, a number of recommendations for the formation of a national action strategy emerged and are included here for consideration.

Features of a National Strategy

A comprehensive national strategy should:

• include the recreation, education, health, and justice sectors
• build on the three theme messages in this report
• focus on child and adolescent development rather than sexuality
• include a complementary but separate Aboriginal strategy
• reflect the multi-cultural diversity of Canada
• be embraced by all three levels of government
• be cost shared between provincial/territorial and federal governments
• be developed in consultation with youth, parents, teachers, caregivers and sector leaders
• pay attention to success stories in Canada or other countries with similar socio/economic realities
• include a goal of reducing teen pregnancy by 50% by 2010
• include a goal of reducing second pregnancies among teen parents by 65% by the year 2010
• include a research component
• consider how teens can connect to sources of support before pregnancy occurs
• be based on the reality of adolescent sexuality rather than adult perceptions of it
• include a menu of options for local customization
• offer tools for building community acceptance and support

M. RESOURCES

Research on Teen Pregnancy

Teenage Pregnancies, Canada, 1975-1989. Surinder Wadhera and Jill Strachan. Health Reports, Vol. 3 No.4, 1991.

Sexual Health Education: a literature review on its effectiveness at reducing unintended pregnancy and STD infection among adolescents. Linda Evans. Canadian Association for Adolescent Health, Vol 8. No. 1 and 2, 1998.

Understanding the Impact of Effective Teenage Pregnancy Prevention Programs. Jennifer J. Frost and Jacqueline Darroch Forrest. Family Planning Perspectives, Vol. 27 No. 5, 1995.

Preventing Adolescent Pregnancy and Associated Risks. Robert Miller. Canadian Family Physician Vol 41, Sept 1995.

Adolescent Pregnancy: Issues in Prevention. Helen Thomas, Alba Mitchell and M. Corrine Devlin. Journal of Preventive Psychiatry and Allied Disciplines, Vol. 4, No. 2 and 3, 1990.

Institutional Barriers to Sexual Health: Issues at the Federal, Provincial and Local Program Levels- Ontario as a Case Study. Maureen Jessop Orton. The Canadian Journal of Human Sexuality. Vol. 3 No. 3., 1994.

Related Websites

Childbirth by Choice Trust. <http://www.cbctrust.com>.

Guidelines for Sexual Health Education (Health Canada). <http://www.phac-aspc.gc.ca/publicat/cgshe-ldnemss/>.

The Kinsey Institute for Research in Sex, Gender and Reproduction. <http://www.indiana.edu/~kinsey/colldesc.html>.

Allan Guttmacher Institute. <http://www.agi-usa.org>.

Best Start. <http://www.opc.ca/beststart/index.html>.

Pro-Teen. <http://www.acsa-caah.ca/Ang.index.html>.

ReCapp: Resource Center for Adolescent Pregnancy Prevention. <http://www.etr.org/recapp/>.

Canadian Women's Health Network. <http://www.cwhn.ca>.

Planned Parenthood Federation of Canada. <http://www.ppfc.ca>.

Teen Health Home Page. <http://www.chebucto.ns.ca/Health/TeenHealth/index.html>.

Newsletters

BC Alliance: Concerned with Early Pregnancy and Parenthood
535 Hornby Street, Vancouver, B.C., Canada. V6C 2E8
604-895-5800

PPT Express: A Newsletter for Teachers and Others Working with Pregnant and Parenting Teens.
Morning Glory Press, Beuna Park, California, USA 90620. 1-888-327-4362.

Manuals For Young Women

Real Girl/Real World: tools for finding your true self. Heather M. Grey and Samantha Phillips. 1998.

Deal With It! A Whole New Approach to Your Body, Brain an Life as a gURL. Esther Drill, Heather McDonald and Rebecca Odes, 1999

Related Initiatives

The Amherst Initiative for Health Adolescent Sexuality: Final Report. 1999.

Teenage Pregnancy. Report by the Social Exclusion Unit, 1999.

Just Loosen up and Start Talking: Advice from Nova Scotian Youth for Improving Their Sexual Health. 1996

Teen Prenatal Study: The Influence of Health Beliefs on Health Behaviours and Birth Outcomes in Pregnant Adolescents. 1998

Policy Documents

Canadian Guidelines for Sexual Health Education (Health Canada). 1994.

A Report from Consultations on a Framework for Sexual and Reproductive Health. Health Canada, 1999.

NOTES

¹ Planned Parenthood Nova Scotia, Just Loosen Up and Start Talking: Advice from Nova Scotian Youth for Improving Their Sexual Health (Halifax: Nova Scotia Department of Health, 1996).

² SIECCAN, 1996, as reported by Alex MacKay in Key Informant Interview. Mr. MacKay is Research Coordinator and Editor of the Canadian Journal of Human Sexuality of Sex Information and Education Council of Canada (SIECCAN), located in Toronto.

³ Carolyn Davis Cockey, "Preventing Teenage Pregnancy: It's Time to Stop Kidding Around," Lifelines (June 1997): 24-40.

⁴ Jennifer Tipper, The Canadian Girl Child: Determinants of the Health and Wellbeing of Girls and Young Women (Ottawa: Canadian Institute of Child Health, 1997) 12.

⁵ Stewart and Associates, 14.

⁶ Health Canada, A Second Diagnostic.

⁷ Maureen Jessop Orton, "Institutional Barriers to Sexual Health: Issues at the Federal, Provincial and Local Program Levels - Ontario as a Case Study," The Canadian Journal of Human Sexuality 3.3 (1994) 30th Anniversary Special Issue, Sexuality Education, SIECCAN.

⁸ Sorenson as quoted by Dahlia Reich, "Struggle Against All Odds," The Sunday Sun, 22 Aug. 1999.

⁹ Dahlia Reich, "Struggle Against All Odds," The Sunday Sun, 22 Aug. 1999.

¹⁰ Ekos Research Associates Inc., Evaluation of the Health Canada Departmental Child Development Initiative, submitted to Strategic Planning and Evaluation Division, Strategic and Review Directorate, Health Canada (1996): 162.

¹¹ Michael H. Boyle, McMaster University, Evaluation of the Community Action Program for Children (CAPC), Impact Evaluation: Preliminary Findings, report prepared for Community Based Programs, Childhood and Youth Division, Health Canada (1999).

¹² The Flett Consulting Group Inc., Brighter Futures for Children of Young Single Parents Evaluation Report, submitted to Health Canada by the Young/Single Parent Support Network (February 1998).

¹³ ---, Youville Centre Crime Prevention Project: Evaluation Results, submitted to the National Crime Prevention Centre by Youville Centre (2000): 30.

¹⁴ S. Speak, S. Cameron and R. Gilroy, Young Single Fathers: Participation in Fatherhood - Barriers and Bridges (Family Policy Studies Centre, 1997).

¹⁵ V. Mann-Feder and C. Norman, "Challenges to Interventions with Adolescent Fathers," Canada's Children 4.3 (1997): 19-21.

¹⁶ Canadian Association of Family Resource Programs, Parenting Programs for Teen Parents: Where Are the Needs, What Exists, What Are the Gaps, prepared for the Childhood and Youth Division, Population Health Directorate, Health Canada (1999): 5-6.

¹⁷ Mann-Feder and Norman.

¹⁸ The Flett Consulting Group Inc., "Strategies for Building an Effective Coalition for the Prevention of Teenage Pregnancy," in Forming a Canadian Coalition on the Prevention of Teenage Pregnancy: Three Background Papers, prepared for the Young/Single Parent Support Network for Health Canada, April 1998.

¹⁹ Tulio Caputo, Hearing the Voices of Youth: A Review of Research and Consultation Documents, prepared for Health Canada, March 30, 1998.

²⁰ Tipper, 12. 21 D. Offord et al., "Ontario Child Health Study," Archives of General Psychiatry 44 (1987): 832 - 836.

²² Norrie McCain and J. Fraser Mustard, Early Years Study: Reversing the Real Brain Drain (Toronto: Canadian Institute for Advanced Research, April 1999) 1-182.

²³ See, for example, the Child, Youth and Family Resiliency Research Forum sponsored by Health Canada - for information: http://www.hc-sc.gc.ca/hppb/childhood-youth/cyfh/child_and_youth/mental_health/resiliency/forum_report.html

²⁴ Paul Steinhauer, "Methods of Developing Resiliency in Children from Disadvantaged Populations," prepared for the National Forum on Health, March 31, 1996.

²⁵ Christabelle Sethna, The Facts of Life: the Sex Instruction of Ontario Public School Children, 1900 - 1950, Ph.D. Thesis: University of Toronto (1995).

²⁶ Donald Langille, ed., The Amherst Initiative for Healthy Adolescent Sexuality (AIHAS) Final Report (Halifax: Dalhousie University, May 28, 1999).

²⁷ Council of Ministers of Education, Canada (CMEC).

²⁸ McCain and Mustard, 1-182.

²⁹ National Crime Prevention Council, Preventing Crime by Investing in Families and Communities: Promoting Positive Outcomes in Youth Twelve to Eighteen Years Old (Ottawa: 1997).

³⁰ Joy G. Dryfoos, Adolescents At-Risk: Prevalence and Prevention (New York: Oxford University Press, 1990).

³¹ ---, "Adolescents at Risk: A summary of Work in the Field - Programs and policies," Adolescents at Risk: Medical and Social Perspectives (Oxford: Westview Press, 1992) 128-141.

³² ---, "Common Components of Successful Interventions with High-Risk Youth" Adolescent Risk Taking, eds. Nancy J. Bell and R. W. Bell (London: Sage Publications, 1993) 131 - 147.

³³ Stout and Kipling.

³⁴ Cynthia Franklin et al., "Effectiveness of Prevention Programs for Adolescent Pregnancy," J Marriage and the Family 59 (August 1997): 551-567.

³⁵ Cockey, 24-40.

³⁶ Cockey, 24-40.

³⁷ Maureen Jessop Orton and Ellen Rosenblatt, Sexual Health for Youth: Creating a Three Sector Network in Ontario.

³⁸ Council of Ministers of Education, Canada (CMEC).

³⁹ W. A. Fisher and J. D. Fisher, "Understanding and Preventing AIDS - Prevention Behaviour; a Conceptual Model and Educational Tool," Human Journal of Human Sexuality 1 (1992): 99 -106.

⁴⁰ W. A. Fisher, "Understanding and Preventing Adolescent Pregnancy and Sexually Transmissible Disease/AIDS," Social Influence Processes and Influence, eds. J. Edwards, R.. S.. Tinsdale, C. Health, and E. J. Posavac (New York: Plenum Press, 1990) 71-101.

⁴¹ Health Canada, Canadian Guidelines for Sexual Health Education (1994) 1-36.

⁴² McCain and Mustard, 1-182.

⁴³ Susheela Singh and K. E. Darroch, 14-23.

⁴⁴ Social Exclusion Unit, 1-139.

⁴⁵ Surinder Wadhera and Jill Strachan, "Teenage Pregnancies, Canada 1975 - 1989" Health Reports 3 .4 (1991): 327-347.

⁴⁶ Social Exclusion Unit, 1-139.

⁴⁷ White House Press Office, White House Fact Sheet on Reducing Teen Births (August 12, 2000).

⁴⁸ National Campaign to Prevent Teen Pregnancies, Press Release (August 8, 2000) <http://www.teenpregnancy.org/99tbpre.htm>.

⁴⁹ "Not me, not now," <http://www.notmenotnow.org>.

⁵⁰ The survey of CAPC/CPNP projects identified 170 local organizations and individuals across Canada who are active players in the field.

⁵¹ See Appendix B for list of names and organizations of key informants.

⁵² Diane Stonehocker, "Bonnyville Teen Pregnancy Research Report" prepared for Bonnyville Healthy Babies Program and Lakeland Regional Health Authority, Bonnyville, Alberta, June 1997.

⁵³ Stout and Kipling.