What strategies can help prevent unintended pregnancy for youth in foster care?

While pregnancy and birth rates among teens have hit historic lows, the number of pregnant and parenting youth in foster care continues to remain disproportionately high compared to youth in the general population. Unplanned teenage pregnancies can result in serious health and educational impacts for both mother and child. Teenage mothers in foster care are twice as likely as older mothers to be reported to a child protection agency for suspected child maltreatment and have their child removed from their care.1

Securing housing and finding employment when transitioning out of foster care is much more challenging for a young mother with a baby or young child. The children of teen mothers (not specific only to teen mothers in foster care) also are more likely to drop out of school, become incarcerated at some point during adolescence, and have babies at young ages.2

These outcomes may be due, at least in part, to teenage mothers in foster care not receiving sufficient support. Elements of the Family First Prevention Services Act are designed to address these issues, with the act including pregnant and parenting youth as a categorically eligible population for prevention services. The Center for the Study of Social Policy has prepared a helpful FAQ on how the law applies.

This issue brief provides a compilation of current strategies and jurisdictional examples on the topic of preventing unintended pregnancies for youth in foster care. It is designed to respond to inquiries from child protection agencies for materials on this issue to inform policy and practice, and ensure the most effective services possible are offered to support pregnant and parenting youth, as well as their families.

Background

Although nationwide statistics are not available, studies indicate that as many as half of the females in foster care become pregnant by age 19, compared to one in five of their peers not in foster care. Further, females in foster care are much more likely to have repeat pregnancies.3

One study reported that nearly 50% of young men in foster care had fathered a child or were involved in getting a partner pregnant, compared with 19% of their peers not in foster care. Given that American Indian/Alaska Native, Black, and Latinx teens in the general population experience disproportionately high rates of pregnancy, it is reasonable to conclude that similar rates exist among American Indian/Alaska Native, Black, and Latinx youth in foster care.

Societal structures and institutional practices place youth in foster care at a higher risk for teenage pregnancy. The National Center for Youth Law describes six factors that can lead to pregnancy among youth in foster care:

  1. Reproductive coercion. Abusive and controlling behavior by a partner (such as sabotaging birth control or applying pressure to become pregnant) can contribute to higher pregnancy rates.
  2. Placement instability. Changes in foster care placement can lead to gaps in health care and education (including sexual education), which can put youth in foster care at risk for pregnancy.
  3. Diffusion of responsibility. Many people — including social workers, judges, and resource parents — are involved in the lives of youth in foster care, but none are formally obligated to engage with youth on issues of sexual education or provide information and access to contraception. Many youth in foster care don’t have a caring, trusted adult in their lives with whom they can confide about personal issues and decisions regarding sex and contraception.4
  4. Lack of policies and training. Service providers and resource parents report that they are not sufficiently trained on youth sexual education and contraceptive options, and that their roles in these areas are not made clear in policies and procedures.
  5. Confusion about legal consent and confidentiality rights. Youth in foster care may experience additional challenges accessing confidential health care services for access to contraception, which may lead to confusion about the rights and services available to them.
  6. Pregnancy history. Research indicates that youth in foster care who already have become pregnant are not consistently provided information about how to prevent subsequent pregnancies.

Strategies for consideration

A child protection agency plays an important role in addressing the health and well-being of all the children in foster care, which includes services to support sexual education and prevention of unplanned pregnancies.5 Child protection agencies can make progress in reducing unplanned teenage pregnancy among youth in foster care by implementing the following strategies:6

  • Empower youth with access to the knowledge they need to make informed decisions. All youth in foster care need accurate information to support their sexual health and protect unintended pregnancies if they choose to be sexually active. Child protection agencies can focus on sexual health as an integral part of the youth’s case plan so that all youth receive the support, knowledge, and tools needed to make healthy decisions regarding sex and pregnancy planning. Child protection agencies can offer sexual education programs for youth in foster care and make this a component of existing programs, such as within their independent living programs. One evidence-based pregnancy prevention program has been adapted for youth in foster care: Making Proud Choices!
  • Collaborate with other systems. Child protection agencies on their own cannot be expected to take on the roles of sexual education and health support to prevent teenage pregnancy. Instead, they need to collaborate with other entities — such as public health, education, judicial, and private sector organizations — to help ensure youth in foster care have access to sexual education and contraception options. In particular, child protection agencies may be able to partner with local public health departments to provide sexual health care services, as well as evidence-based pregnancy prevention programs.
  • Develop policies and procedures. Child protection agencies can develop and implement specific policies and procedures to help prevent unplanned pregnancies and promote sexual health among youth in foster care. These should include clarifying the roles and responsibilities of all adults who care for the youth — caregivers (including foster parents), caseworkers, and other supportive adults. For example, it might be necessary to clarify who is responsible for ensuring that the youth have access to regular health care screenings once they become adolescents.
  • Provide training for caregivers and caseworkers. Many caregivers and caseworkers may feel unprepared to talk with youth in foster care directly about personal issues like sex and contraception. Training should be provided on how to talk to youth in nonjudgmental, frank and supportive ways about sexual health, contraception and pregnancy prevention, and healthy relationships.7 Training should include information on the psychological reasons that youth in foster care are more likely to become teenage parents.
  • Implement culturally appropriate pregnancy prevention strategies. Given disproportionately high rates of pregnancy among teens of color, sexual education and pregnancy prevention strategies that are tailored to specific races and ethnicities — and corresponding to their religious, cultural, and social beliefs — should be developed and implemented. Between 2010 and 2015, the Centers for Disease Control and Prevention, with the U.S. Department of Health and Human Services, funded nine state and local organizations along with five national organizations to demonstrate the effectiveness of providing culturally and linguistically appropriate pregnancy prevention programs to young people. As a result, several helpful resources were developed on how to work with diverse communities and raise awareness about the link between teen pregnancy and the social determinants of health.
  • Provide access to high-quality health care. All youth in foster care are entitled to health screenings. Yet due to frequent changes in placement and other issues, they may not have a regular health care provider or know where to find a clinic. Caseworkers should ensure that all youth, starting at puberty, receive regular screenings that provide age-appropriate information about sexual health and pregnancy prevention, including methods of contraception and how to access them. Particular attention should be taken to ensure that youth of color receive high-quality health care, given that national evaluations consistently find that people of color receive lower quality health care than whites.
  • Provide access to trauma-informed mental health care. Some youth in foster care may become pregnant intentionally because they are seeking a sense of family and belonging, or a plan for their lives following foster care. For these youth (and all youth in foster care), trauma-informed care can help mitigate the effects of adverse childhood experiences, promote self-esteem, and develop a sense of purpose in life.
  • Prepare youth for pregnancy prevention after foster care. Research indicates that the risk of pregnancy increases in the first few years after exiting foster care. The Midwest Study, a longitudinal analysis of young adults exiting care, found that 33% of 17- and 18-year-old females preparing to transition out of foster care had been pregnant at least once. By age 19, nearly half had been pregnant, and by age 21, 71% had. Youth who are aging out should receive information, resources, and referrals so they will be prepared to prevent pregnancy after they have exited the foster care system.

Jurisdictional examples

Although many child protection agencies have programs to address the needs of pregnant or parenting youth in foster care, few have programs or policies specifically designed to prevent pregnancy for youth in care. Among those that do, approaches vary:

California

In 2013, California passed a law that requires child protection agencies to inform youth in foster care about their reproductive and sexual health care rights. As a result, Orange County Social Services Agency developed a Reproductive Health and Parenting policy that clarifies the roles and responsibilities of caseworkers, caregivers, and the agency itself. Every six months, agency staff must provide youth in foster care information about reproductive and sexual health, as well as their rights to access services. Staff and caregivers also must attend trainings that support the implementation of this policy.

In 2017, California adopted a comprehensive Foster Youth Sexual Health Education law, which included new training requirements for caregivers, social workers, and judges. The Reproductive Health Equity Project for Foster Youth, which brings together youth in foster care and the agencies that serve them with a goal of reducing unintended pregnancy, works to advance the priorities of the law, including the development of trainings and a case manager guide.

Hawaii, Alameda County (Calif.), Minnesota, North Carolina, and Rhode Island

The evidence-informed sexual health curriculum Making Proud Choices! is designed to help teens understand behaviors that put them at risk for pregnancy and sexually transmitted infections (STIs), and to empower them to reduce risk through healthy decision-making. In 2011, the National Campaign to Prevent Teen and Unwanted Pregnancy (now Power to Decide) and the American Public Human Services Association started a project to reduce teen pregnancy rates among youth involved in the child welfare system by adapting Making Proud Choices! for youth in foster care. The project supported five teams of state and local child welfare professionals as they implemented the program. The main message of the adapted curriculum is: “Youth can make proud and responsible choices in spite of what has happened to them in the past.”

The five teams established partnerships between child protection and public health agencies that enabled the programs to be implemented on a larger scale and with a focus on sustainability. Since 2013, the teams have been delivering the program to youth in foster care and participating in an ongoing process evaluation, which is beginning to provide valuable insight about the types of partnerships and support systems that need to be in place to incorporate teen pregnancy prevention into daily child welfare practice. Hawaii, for example, has made the curriculum part of its ongoing independent living skills program. Hawaii also provides trainings for foster parents and caseworkers about how to talk to youth about sexual heath.

Maryland, California, and Oklahoma

Power Through Choices (PTC) is a sexual education and skill-building curriculum designed for youth living in foster care and other out-of-home settings, with the goal of reducing risks related to teen pregnancy and STIs. PTC is designed with and for the youth. With a focus on self-empowerment and the impact of choices, PTC uses interactive learning to help youth avoid risk-taking sexual behaviors. The curriculum challenges youth to set goals for their future and helps them recognize the importance of making healthy choices to accomplish those goals. In Maryland, California, and Oklahoma, PTC was implemented in group settings.

Connecticut

Connecticut used a Personal Responsibility Education Program federal grant to build a cross-systems collaboration focused on reducing unwanted teenage pregnancy. The partnership includes the child welfare, education, public health, and mental health systems, as well as other community partners. Connecticut implemented Teen Talk, an intervention program developed by Planned Parenthood of Southern New England, with a goal of decreasing rates of pregnancy and STIs among youth ages 13 to 19. This program was designed to provide sexual health education and facilitate access to sexual health care services in order to delay sexual activity, prevent unplanned pregnancy, and prevent STIs. Teen Talk uses the Health Belief Model’s behavior change theory, and is a 10-hour program (four 2.5-hour sessions) for youth in child welfare group placements.

1 Hoffman, S. D. (2006). By the numbers: The public costs of teen childbearing. Retrieved from The National Campaign to Prevent Teen Pregnancy website.
2 Hoffman, S. D. (2006).|
3 Winter, V. R., Brandon-Friedman, R. A., & Ely, G. E. (2016). Sexual health behaviors and outcomes among current and former foster youth: A review of the literature. Children & Youth Services Review, 64, 1-14.
4 A small study examined the lack of support African American youth may feel and included some recommendations: Ross, C., Kools, S., and Laughon, K. (2020) “It was only me against the world.” Female African American Adolescents’ perspectives on their sexual and reproductive health learning and experience while in foster care: Implications for positive youth development. Children & Youth Services Review, 118, https://www.sciencedirect.com/science/article/abs/pii/S0190740920306824?via%3Dihub
5 Finigan-Carr, N., Steward, R., & Watson, C. (2018). Foster youth need sex ed, too!: Addressing the sexual risk behaviors of system-involved youth, American Journal of Sexuality Education, 13:3, 310-323, DOI: https://doi.org/10.1080/15546128.2018.1456385
6 For additional tools, research, and recommendations related to prevention and working with pregnant and parenting youth in foster care, please see the following resources:

7 Harmon-Darrow, C., Burruss, K., and Finigan-Carr, N. (2020). “We are kind of their parents”: Child welfare workers’ perspective on sexuality education for foster youth. Children & Youth Services Review, 108, https://doi.org/10.1016/j.childyouth.2019.104565

Categorized in: Issue Brief, Older youth, Questions from the field, Resources, Safe children, Youth outcomes
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