Rural teens have higher pregnancy and birth rates than urban teens. They also have less access to information and good health care. There’s a relationship between these two sets of facts, and we need to address it.
Poor, minority, urban girls have become the face of teen pregnancy in the United States. But new data from the National Campaign to Prevent Teen Pregnancy shows that rural teens have a much higher rates of pregnancy and birth than their urban counterparts. In other words, rural teens are both more likely to get pregnant and more likely to give birth as a result of pregnancy.
Why? Commentators on both sides have rushed to put forward theories ranging from insufficient sex education (producing a higher pregnancy rate) to rural teens holding values that promote parenting over abortion (leading to a higher birth rate). Both analyses miss the mark. The first is incomplete while the second is speculative at best. Both fail to see teen pregnancy and birth in the context of the larger tapestry of rural health.
To make sense of rural pregnancy and birth rates, we must do three things:
Putting Pregnancy in Context
Widespread health disparities are a reality in the United States. Rural Americans live with the burden of poor health at considerably higher rates than those living in suburban or urban communities. Rural counties have fewer primary care physicians and emergency room doctors. Treatment options are often nonexistent or too far away, problems exacerbated by a lack of rural public transportation. Rural people are less likely to be covered by Medicaid and less likely to have employer-sponsored private insurance, both of which can create insurmountable financial roadblocks. Additionally, using health care that carries social stigma—including services to treat mental health, substance abuse, reproductive health and intimate partner violence—can be difficult in rural America, where tight-knit communities can amplify concerns about social standing and confidentiality.
All of these barriers add up and take a toll. Lack of access to health care for rural Americans creates physical and emotion stress, reduces the likelihood of follow-up care, and decreases the support patients get from family, according to a Stanford University report.
Teens are part of rural communities and, not surprisingly, face the same challenges getting good healthcare: doctor shortages, geographic and logistical barriers, financial impediments, an increase in stress that exacerbates poor health, and social stigma. These challenges apply to teen pregnancy prevention and management.
Teen Pregnancy Stereotypes
The conversation about teen pregnancy can be riddled with stereotypes and without nuance. Our biggest critique? All too often the larger community context gets left out of the discussion as we zoom in obsessively to the level of the individual girl. What about the “structural landscape” around many rural teenage girls – the health-care services, economic opportunity,
educational support, and all the other influences on women’s access to and use
of reproductive health services? This landscape is full of hurdles, many of which don’t exist for suburban and urban teens. Rural teens often lack basic information about how to prevent pregnancy. Many states do not mandate sex education and, when provided, only some states require teens learn about contraception. A higher proportion of largely rural states like Mississippi and Oklahoma take the opposite approach, mandating abstinence education but not mandating education about contraception. Though studies suggest that teens are waiting longer to have sex, many teens—both rural and urban—are sexually active. Without proper education about how to prevent unintended pregnancy, teen pregnancy in rural America is unlikely to decrease.
Once pregnant, the information gap becomes more profound. All teens—urban and rural—encounter health-care and social-service providers who are unable or unwilling to guide them to safe and healthy support around adoption, abortion, and parenting. Abortion, in particular, is often dislocated from mainstream health and social services through a combination of restrictive laws and policies, social opposition, and stigma. For rural teens, these problems are especially acute, because healthcare is often dislocated overall.
Developing a Better System
Any teenager—no matter where she lives—should have access to all her options when facing pregnancy. But what does a good system for dealing with teen pregnancy look like?
If a pregnant teen decides to continue her pregnancy with the intention of parenting, she should be referred to prenatal care specifically geared to the medical, psychological, and financial needs of pregnant rural teens. This type of care can be very challenging to find in rural America. Pregnant rural women often are at increased risk of late or no prenatal care. On top of the general barriers to finding good health care in rural communities, these women may not be able to find services near them that address teen-specific pregnancy and parenting issues. Health and social-service providers serving rural communities must be prepared to refer teens to health-care providers able to treat their specific needs, if we are going to ensure that teens with an unintended pregnancy can gain access to prenatal care.
If a pregnant teen decides to continue her pregnancy with the intention of placing a child up for adoption, again, health-care and social-service providers must have strong referral networks to ensure that teens are referred to adoption agencies that preserve teen choice and autonomy. Pregnant teens who are interested in adoption should work with adoption agencies that help teens develop both a plan for the adoption as well as a plan to parent should the teen decide that she would like to become a parent. Teens must fully understand the different types of adoptions, open or closed, and feel prepared to select adoptive parents who will respect the teen’s decision about the type of adoption that is right for her. Adoption agencies must respect the full spectrum of choices before rural teens, including the choice to change her mind about the adoption in favor of the decision to parent or the decision to elect abortion care, if the teen decides that these are the right choices for her.
If a pregnant teen chooses abortion, health and social-service providers have a role. Again, strong referral networks among these providers are absolutely critical to ensuring that rural teens can gain access to timely care and find appropriate abortion providers. As with all health-care services, abortion providers are by and large not located in rural America. The Guttmacher Institute estimates that 97% of non-metropolitan counties in the United States do not have an abortion provider. Rural states like North Dakota and Mississippi each have only one clinic that provides abortion care, and South Dakota has only two abortion providers. Doctors who provide abortions tend to be located in urban areas.
Finally, rural teens, more so than their urban counterparts, must navigate so-called Crisis Pregnancy Centers. Pregnant teens looking for information on abortion and adoption are often directed to these fake medical clinics. Crisis Pregnancy Centers—whose sole aim is to stop women from obtaining abortion care—exist all over the country and proliferate especially in rural America. These fake medical clinics pose as places where teens can receive unbiased information about their choices, and even obtain abortions. Instead, Crisis Pregnancy Centers have been documented deceiving patients by telling them that they are past the gestational limit for obtaining abortion care, rescheduling fake abortion appointments to push women past the gestational limit of the actual abortion provider, and, in extreme cases, even giving pregnant women negative pregnancy tests. Strong referral systems are the key to help all teens, but especially rural teens, get unbiased information, counseling, and medical care
Data in Context
Structural barriers to rural healthcare are key to understanding the higher pregnancy rate among rural teens. Those same structural barriers, with the specific challenges that come with gaining access to abortion, may help us understand higher birth rates among rural teens. But putting aside theories of causality for now (a smart idea given the absence of sturdy research on what drives these trends), we are sure of one thing: Pregnant teens in rural America need support.
As people who care about rural young women and girls, let’s create a system that meets their needs.
Rebecca Hart is the associate director of programs at Provide, Inc,. a national non-profit committed to access to safe abortion for all women in the United States.