Clinics' Effect on Birthrates Overstated, Study Finds
A pioneering program of school-based health clinics in St. Paul has failed to live up to its reputation for curtailing teenage-pregnancy rates, a study published in the January/February issue of Family Planning Perspectives contends.
The study notes that positive reports about the city's Maternal and Infant Care Project, which was established in 1973 to advise teenage women about sexually transmitted diseases, contraception, and pregnancy, helped motivate communities across the country to open school-based clinics.
But the new study, which looked at birthrates of students over a 16-year period who attended five St. Paul-area high schools, found no evidence that the clinics had an impact on the rate of births. Instead, the evidence showed that the numbers of women having children fluctuated dramatically from one year to the next, due to a wide variety of factors.
The original study, conducted by school officals at the Mechanic Arts High School in the late 1970's, claimed that teenage birthrates at that school fell from 79 births per 1,000 female students to 35 per 1,000 in a three-year period after the clinic opened--a 56 percent decline.
The school's methodology was faulty, however, argues the new study, which was conducted by Douglas Kirby, the director of research of E.T.R. Associates in Santa Cruz, Calif., researchers from the University of Minnesota, and a local school official.
New Statistical Method
Using a new statistical method of assessing birthrates, Mr. Kirby's investigation revealed that the teenage-birthrate rate was not significantly lower after the clinics opened. In fact, the overall rate went up, although researchers attributed the change to other factors.
In the five years preceding the opening of the clinics, 22 female students per 1,000 gave birth, while 29 per 1,000 gave birth in the six years that followed, the study found.
The researchers criticized the earlier study's method of comparing post-clinic birthrates to a single pre-clinic year, arguing that one year was insufficient to make a statistically sound comparison.
The clinic also failed to investigate the birthrates of students who dropped out of school, the Perspectives study points out.
After looking at hundreds of local documents, the authors compared female students' school-attendance records with the names of teenage mothers on birth certificates from 1971 to 1987.
They used data from county health records to determine approximate dates of conception, and then compared those dates with school records to see whether the mother had conceived while she was attending school.
The study represented the first effort to use official health records to compile birthrate statistics on individual schools, Mr. Kirby said. The method also allowed researchers to gather information on grade level and the race of the mother.
Other inquiries have tended to rely on the personal knowledge of clinicians or school officials, Mr. Kirby explained.
The study also suggests that a number of factors, such as economic status, ethnicity, and changing student populations, all affect the rate at which women become pregnant and have children.
"Just because a rate increased or decreased after a program was implemented did not mean that the program produces that effect,'' Mr. Kirby said. "It's caused at least partially by the element of chance that occurs when couples engage in unprotected sex.''
In one year, 10 percent of female students might become pregnant, he said, while only 3 percent might the next year.
'One Piece of the Picture'
Clinicians and backers of school-based clinics said they were not surprised by the results of the study and argued that the primary goal of the facilities is not to reduce birthrates.
"There are too many factors that go into it,'' said Donna Zimmerman, the executive director of Health Start, a nonprofit organization that runs the St. Paul school clinics.
Since the first school-based clinic opened in 1973, the teenage birthrate in St. Paul has doubled, Ms. Zimmerman said, adding that other factors, such as immigration, can also play a role in changing birthrates.
Previous studies have attested to the difficulty of changing adolescent sexual practices, she noted.
"School-based clinics are but one piece of the picture,'' she said.
The authors of the study emphasized that they were not seeking to discredit the work of the clinics. School-based clinics are a worthy enterprise in many areas, they said, because students also use them for routine medical problems.
The authors also urged educators not to compare the record of St. Paul, which has a low teenage birthrate and a good public-health system, to that of the rest of the country.
Family-planning advocates also said the study will not have any impact on the reputation of reproductive-health clinics as a whole.
"The study in no way invalidates [the clinics'] effectiveness,'' said Jane Johnson, a vice president of Planned Parenthood of America.