rsm92

= Introduction -

“The Doll that Grew Up” - <= span lang=3DEN-GB style=3D'font-family:"Courier New";mso-bidi-font-family:"Times= New Roman"'>Lorna’s bedroom was like that of any fourteen year old - walls papered with posters= and cut outs from teen magazines and bits of&n= bsp; record covers - a foot= ball scarf draped round the light switch and a scatter of old cinema tickets and memorabilia blue-tacked to the mirror. The floor obscured by discarded scho= ol books and dirty underwear with the odd sweet wrapper, cotton wool balls and mother’s ‘borrowed’ best shoes. Mixed in among the tea sh= irt collection on the bed lay the required row of furry animals and mascots - teddy, pink pig, Emu puppet, cabbage patch kid = doll which she had pleaded for on her tenth birthday, grotesque stuffed ‘something’ which Mum won for her at the Easter fair ..... and a baby.

She had never gone out much; was certainly not promiscuous and had no boyfriend then, now or ever. The baby = was conceived on an ill-fated outing with friends when the little ‘stay at home’ was persuaded to have one taste of the bright life. On return from hospital with little David she sat shell shocked in her room - not knowing whether to play with baby or toys and alternating between them with mother anxiously hoveri= ng. She slept with David beside her in his carry cot and Teddy snuggled up to h= er inside the covers.

Fifteen years later she still has n= o boyfriend, she hardly ever goes out except to visit Mu= m. David is a fine boy, quiet and well mannered and his mother’s only companion.

= * * * &= nbsp; * *

Sonia also got pregnant at fourteen= but was delighted to have her baby. Her one and only boyfriend stuck by her and they are now married with a delightful family of four children ranging in a= ge from 14 to 6. Sonia is working and has taken up professional training. She would like to become a therapist.

= * * * &= nbsp; * *

The lives of young mothers have tak= en many turns along differing paths in the fifteen years that we have followed them. For some it has been a success story, for others the road has been pa= ved with disaster - some are lonely and sad - others have come through pain and hardship with immense fortitude.

Whatever the outcome - the one mess= age that we need to learn from these stories is not to prejudge young parents - there are many stereotypes and many false impressions and whatever concept = we may have of teenage parenthood we are likely to be wrong - we need to keep a completely open mind and remember that all parents - young or old, are individuals and deserve unique attention.

= * * * &= nbsp; * *

= The study - &= #8220;Are you my sister, Mummy?” - Early studies on teenage pregnancy - = This first part of the survey provided an important database regarding pregnant schoolgirls and their circumstances. It was a vital piece of work since previously available information had dealt with American groups whose population was not comparable in any demographic or social sense. We needed information on our own population to examine the factors, risks and social stresses of the environment pertinent to British teenagers. (Birch 1987)1 An information base was impo= rtant in terms of understanding factors which led to early pregnancy and childbea= ring - what motivated young people, what the family’s influence might be a= nd how we might intervene to help at any stage.

Contact was made with every school = girl who became pregnant in a specific geographical area - covered by a London Health District. All school girls falling pregnant and who by intent or by default continued their pregnancies within a time limit were included - addition to the group began in 1980 and ceased in 1987. The first 126 cases were analysed for baseline data and formed part of an MD thesis (Birch 1986) ^{2; 150 cases were reported in the book
“Are you my sister, Mummy?” ; 174 entered long term study =
which
is fully described in “The child that rocks the cradle” (Birch
1996)³.}

The initial piece of research invol= ved a number of stages :-

· base line information gathering dur= ing the pregnancy

· data regarding the birth=

· six week follow up

· six month follow up

· one year follow up

· two year follow up

The fifteen year survey. = Further survey points have been:-

· five years follow up

· ten years follow up

· fifteen years follow up<= /span>

= Findings and comments - It is hard to do justice in a paper to the findings of a fifteen year survey w= hich has generated volumes of data on this population - both in terms of statist= ical facts and , perhaps even more importantly,= in terms of qualitative information. The following is thus a brief summary of some of the more pertinent features of the study.

= A. Fertility and Repeat pregnancy Those who have been pregnant as schoolgirls are a highly fertile population. They begin their childbearing career at an early age and are likely to remain fertile during a large segment of their life span. The rate of repeat pregnanci= es continued to be high throughout the years. Each follow up showed a high num= ber of girls had become pregnant again since the last interview.

Childbearing patterns- Three sub-populations were identifiable :- =

1)&= nbsp; Single pregnancies - girls who ha= ve one pregnancy only.(12%)

2) Constant repeaters - who maintain a high level of repeat pregnancy throughout (68%)

3) Late repeaters - girls wh= o have one pregnancy as a school girl then do not have repeat pregnancy until they enter a second later stage of child bearing (adult childbearing stage) (20%= )

This group of young women have a higher fertility rat= e than other girls of the same age. The risk of pregnancy is particularly high dur= ing the first year after the birth of the first child when teenage mums are eig= ht times more likely to get pregnant (250 live births per thousand) than the general teenage (< 20) population (30 per thousand) ⁴. <= /o:p>

Girls who had been in care tended to have more pregnancies over the years than those who had not been in care. G= irls from more difficult circumstances may have a greater need to repeat their pregnancies. They form a greater percentage (90%) of the ‘constant repeater’ group.

B. Patterns of Relationships.

Staying Together-Single Partners. = The myth of the promiscuous schoolgirl mother was exploded when it was noted th= at at the time of conception, over two thirds of the couples had been together= for more than six months and for over two thirds of the girls this was their fi= rst sexual relationship. Fifteen years later over a third of the girls (39%) have only ever h= ad one boyfriend. For another 12% the ‘rescuing’ boy who entered t= heir lives at an early stage during pregnancy or in the firs= t months of the baby’s = life and became an ‘early replacement father’ was the only other man= on the scene. So 51% of the girls only had one significant relationship.<= /o:p>

Multiple Partners. = Nearly half the sample (49%) follow a serial monogamy o= f more than two partners. Girls who ‘bounce’ from one man to another without breaking down have a h= igh level of flexibility which allows them to adapt to these differing domestic arrangements - but a low ability to learn from their experiences - they thus continue to ‘repeat’ their pattern. The parade of parenting partners takes a toll - = both on the children - in terms of instability,= inconstant boundaries and on the mothers experiencing recurrent loss= and being left ‘holding the baby’ quite literally over and over again. A ne= ed to fill a ‘father shaped’ gap in her life coupled with low self es= teem means that she is likely to form a relationship with an inadequate man or a= boy with problems of his own. He is placed under enormous pressure to cope with= a needy ‘instant family’. He too does not enter the arena in a pristine state - nor does he leave the scene unscathed.

Asexual lives.Girls without Boyfriends.&n= bsp; 10%= of the girls did not ever have a real relationship with a boy after the birth of their first and only child. They feel let down by society and by the father of their child and do not seek sexual relationships in the f= uture. Some never actually had a boyfriend EVER.

The Late Relationship - the ‘Adult’ Relationship.= = Many mothers who had been through painful periods in their lives made a delibera= te change of life-style and passed through a threshold in identifying with the= ir new ‘adult’ selves.They had ‘teen’ and later ‘adult’ lives

= C. Families

There are many different family structures. Our society in ge= neral has moved away from the single idea of the nuclear family - mother, father = and two children - as being the only acceptable pattern. Single parent families= are much more the ‘norm’ than when this study commenced in the early eighties. It has also become = more acceptable for couples to live together outside marriage.=

The family of origin of the teenage mothers= . They generally came from large single parent families with an average of fi= ve children. Two thirds of their natural fathers were absent from the household and the ‘fath= er figure’ was usually a man who moved in and out of the ‘family&#= 8217; fathering more children and then going on his way. Neither fathers nor stepfathers figured significantly in most girls = lives.

Just under half the girls (45%) got= on with their mothers but in half the of these case= s - a fifth of the whole (21%) - the relationship was described as ‘over close’ and suffocating. The families fell into the main groups of - good relationships with both paren= ts ; absent or weak father and dominant or poor relationship with mother; both parents absent or ineffectual. To a large extent this family pattern was recreated in the next generation.

= Baby Fathers - It was noted in the early part of t= he study that the boyfriends of schoolgirl mothers tended to be of similar background and characteristics - dropping out of school, not often in employment, having similar family histories of school age pregnancies with regard to their mothers and sisters and had similar needs to become parents= .

Despite all the negative connotatio= ns and difficulties a reasonably high number of the natural fathers of the fir= st born children were still in contact with their offspring at the age of two years. (45%). Past this stage a number of ‘baby-fathers’ dropped out of the children’s lives with t= he result that by the time the children were in their teens themselves only 20= % of fathers were still in touch with their children. This figure was significan= tly different for the partners of young mothers who had been in care - they were ten times less likely to maintain contact with their children (2%).

= Grandmothers often have a very hard time coping with their children a= nd grandchildren. It is also extremely difficult for a child brought up by grandparents who may be too old to do some of the ‘parental’ ta= sk or have fun. Children are also immensely bereaved when grandparents who have been their prime carers eventually die. Children who had been brought up by grandparents were marke= dly deprived in comparison to those brought up by their parents.

= D. The Children

= Child Care -Placement of Children The majority of children were bro= ught up by their natural mothers and lived with them throughout the time of the survey. 80% of the children were with their natural mothers at 5 years and = this dropped very slightly to 78% at 10 years and 75% at 15 years. Splitting the groups into subgroups of girls who have been in care and those who had not, once more the care group had a worse prognosis with only 62% continuing to = care for their children at 15 years as opposed to 82% of the non care group.

= Children’s Views and Lifestyles The children of school age mothers = are like= other children of the same age. As teenagers they have similar likes and dislikes= and indulge in all the usual teenage activities. In the main they came across a= s a confident and healthy group.

= School - = Forty percent of the boys reported being bullied at school, but often this was part of a two w= ay process of disruptive behaviour since 70% had behavioural problems relating to violence in school, fighting and disregarding teachers. A quarter of the boys&nb= sp; had been involved in something illegal.

The rates for girls were lower. 20% had behavioural problems at sc= hool and were disruptive in class. 35% were bullied at school. 6% had been invol= ved in minor crime.

= Relationships with Parents - 80% of boys and 95% of girls said t= hey get on with their parents. Ha= lf the boys (50%) and rather more of the girls (70%) said they could talk to Mum about = most things and 50% of boys and two thirds of the girls said they would confide in their mothers if they had problems.

Pregnant schoolgirls often lack a father figure in their lives. Their sons seem greatly affected by lack of a father within the household. It is the boys who appear to be reaching out t= o a paternal figure, miss their fathers and get involved in early s= exual liaisons possibly in an attempt to identify with the father figure. This ax= is of father / teenage son has often previously been ignored in the study of causes of early pregnancies. A significant factor in prevention of early pregnancy is the psychological and emotional status of the boy.<= /span>

Sex Education. = 50% of boys = and 75% of girls had knowledge of sex education, 10% of boys and 50% of girls learn= ed this from their mothers which was a significant improvement on the previous generation.

Sexual Activity. = Boys are more sexually active than the girls some started as early as 11 Most us= ed condoms but 15% boys had unprotected sex.

Conclusions.

The influence of the care system is pernicious and young mothers who have been in care do worse than those who = have not over a number of different dimensions. They have more children, they ha= ve more relationships, their relationships are less stable and more of their children end up in care themselves ...&nbs= p; But is this an influence of the care system alone - does being a you= ng Mum who has been in care differ from being an older Mum who happens to have been in care? If you ar= e a family on low income, you are more likely to have a daughter who is pregnant young ... if you are in an area of social deprivation ... you are more like= ly to have a schoolgirl who is pregnant .... School= girl pregnancy is very much a ‘culture of poverty̵= 7;(“Schoolgirl Pregnancy - a Culture of Poverty”)⁵ and traps deprived gir= ls in a cycle of derivation.

“The repercussions of teenage childbearing are long lasting: the young parents acquire less education than their contemporaries ; they are more often limit= ed to less prestigious jobs and the women, to more dead end ones. ..” (Card= and Wise 78)⁶. “The adolescent mothers consistently experienced great difficu= lty in realising their life plans when compared to their classmates who did not become pregnant premaritally in their early tee= ns ..” (Furstenberg 76)⁷. If you = are in care you are more likely to get pregnant early - in our sample 22% of the pregnant = girls had been in care at a time when less than 2% of the child population of the area was in care. The important message is that if families are supported a= nd the effect of social deprivation and poverty is minimised. then not only will the rate of ‘premature’ motherhood diminish - but those mothers who do start their families early will be able to raise their families happily and well.

There is a group of girls who wish to become pregnant at an early age, are ready for it, are mature emotionally and physically and if it were not for the stigmatising of our society and the lack of support - they would have every chance of success. Others are immature, they neither desire motherhood nor feel able to cope <= span class=3DGramE>with the= birth of their children, they may pass the child over to the care of others. Between these two extremes we have= a whole spectrum of girls who though not actively and consciously seeking pregnan= cy, nevertheless are happy to be mothe= rs and make some emotional or existential gain by virtue of their ‘mothering’ status. Most important in this context is the gain = in self esteem and a sense of ‘purpose’in life. Even from the other side of the Atlantic, where the general view is perhaps = more pessimistic than ours, there = are encouraging comments - “Some adolescent parents do overcome the handi= caps imposed by adolescent childbearing; they complete their education, get dece= nt jobs, avoid welfare dependency ...” (Furstenberg and Crawford 1978)⁸

Most studies from the USA show that= children of teenage mothers do badly in comparison to their = peers. (East and Felice 90)⁹ &nbs= p; “ .... The children of teenage moth= ers are distinctly worse off throughout childhood than the offspring of older= childbearers.” (Furstenberg, Brooks-Gunn = and Chase-Lansdale 89)¹⁰.&nb= sp; In Britain the same factors operate to an extent but are highly dependant on social status of young mothers rather than her age per se. Children can bear a heavy burden when they are expected to fulfil the role = of ‘little parent’ to their child mothers. These children fill a n= eed in their = parents, provide love, fulfilment and self worth. Perhaps in some ways this is= a valid role? These children are valued, wanted and loved in return. What more could a child want?

The male first born children seem to fare worse. Daughters take the role of sisters and at least have a mother as role model and confidante - something the young mothers wish they had themselves. Sons have no role model,do not know quite how to relate to their mothers who they often end up ‘fathering’. Single mothers can lack the knowledge and resource= s to appreciate and provide for their developing sons needs. These very first born sons a= re more prone to early sexual acting out and their numbers swell the ranks of the less supportive and less stable teenage fathers for the next generation.

Families certainly play an important role. Girls tend to recreate their family of origin. Those with good suppor= tive families fare better. Those <= span class=3DGramE>with no = families do worse. But there are casualties and surprise successes in all life style= s.

Being a young parent is not the end= of your life and dreams - it need not be a life of toil and hardship - sadly f= or some unfortunate families it can be - but given adequate support young parents can do remarkably well. Perhaps it is time to = stop condemning young families and instead try to help them. To look for the positive attributes of young parents and work on them rather than spell doom and gloom with negative statistics. Young mothers have the potential to suc= ceed in all walks of life - if we give them the chance to do so.

= References -

1. Birch DML ̶= 0;Are you my sister Mummy?” Y= outh Support Publications ISBN 1 8= 70717 00 7 1987

2. Birch D.M.L. "Schoolgirl pregnancy in Camberwell; A population study of inner city schoolgirl pregnancies, motherhood and two year follow up&q= uot;. MD thesis University of London 1986.

3.= Birch DML “The Child that Rocks the Cradle” Youth Support Publications 1996<= /span>

4. Live Births per thousand women - Fertility Rates - OPCS FM1 96/1 May 1996

5. Birch D.M.L. "Schoolgirl Pregnancy - a culture of poverty" Proceedings of International Medical women's federation Conference Sorrento 1987a (available from Youth Support)=

6. Card J.J.; Wise L.L. “Teen= age Mothers and Teenage Fathers: The Impact of Early Childbearing On the Parents’ Personal and Professional Lives&= #8221; Family Planning Perspectives Vol. 10 No 4 August 1978

7. Furstenberg= F.F. “The Social Consequences of Teenage Parenthood” Family Planning Perspective= s Vol. 8 No 4 148-164 August 1976.

8. Furstenberg= F.F. ; Crawford A.G. “Family Support : Hel= ping Teenage Mothers to Cope” Family Planning Perspectives Vol. 10 No 6 Dec. 1978

9. East P.L.; Felice = M.E. “Outcomes and Parent-Child Relationships of Former Adolescent Mothers= and their 12-year-old Children” Developmental and Behavioural Paediatrics Vol. 11 No 4 175-183 August 1990.

10. Furstenber= g F.F.; Brooks-Gunn J.; Chase-Lansdale L. “Teenage Pregnancy and Childbearing” American Psychologist Vol.= 44 No 2 313-320 February 1989.

In my presentation I’d like to talk a little bit about the trends that we see globally, what do those tren= ds mean and then what is it that we know about programming for young people th= at makes a difference and how do we organise programmes that support young peo= ple in a time of tremendous change.

I would like at first to focus on s= ome of the social and demographic changes. Changes that we see across the world today are nothing short of dramatic. We see for example that 30% of the wor= lds population are young people between the ages of 10 and 24; 83.5% of that population of young people live in developing countries. The number in many countries, for example in sub-Saharan Africa, the number of young people

under= the age of 24 are five times grea= ter and even under the age of fifteen - in some of sub-Saharan Africa half the population is under the age of fifteen - that applies to Kenya, in Mali in Mozambique .

In many developing countries young people represent 25% of the population, compare that to France or Japan where it is 13 % or China 16%. Clearly young people today represent a major force and a major part of= the population throughout the world.

Well some of these trends seem to t= ie in with what we see in life expectancy. As life expectancy has increased dramatically in industrialised countries at the upper age range - we have n= ot seen comparable rises in developing countries as yet. In = Latin America and in Africa where we have seen such changes, they have been in the youngest age groups. Their child survival has increased dramatically. The consequence of child survival, the work that was done in the 1970s and 1980s is that we now have= a bolus of young people moving into adolescence and into adulthood.

It is because of those demographic changes as well as because of those social and economic changes that are happening in those countries that today adolescence is on an International agenda in a way that it never has been before. Some of the social changes t= hat we are seeing includes migration, and migration is not just betwe= en countries but it is within countries as well.

Its rural to urban migration and wh= ile there as always been rural to urban migration, it has been the men, males w= ho have travelled to the urban areas to work for the week ad to the return home to the rural areas back to the village at the weekend. But what we are now seeing is a greater migration of young women, more than young men who are travelling fr= om the country to the city, so you have in a city like Bogota for example a three five to four ratio of females to males under the age of twenty four.

Another change that is occurring is= the rising value of education. That change is being seen around the world again where the pressure is increasing and the desire is increasing among young people for attending school and to stay in school, so there is a hope that = with education will come social development and social progress. These changes in many ways are akin to changes that we saw in North America and in Europe in 1910 and in 1920. Prior to 1910 there was virtually no universal educati= on mandated, these changes were all within this century for industrialised countries and are beginning now I developing countries as well, additionall= y as well what we are seeing which goes along with education is a rise in the ag= e of marriage, well if you live in a world village and you are 12 or 13 years of= age and education is not in your career path anyway then age of marriage doesn’t pose any problems, child bearing doesn’t pose problems large families, high infant mortality in fact had a certain protective valu= e, but today, with these changes in urbanisation and education there is likewi= se a push, in may countries there is a very deliberate strategy, of family plann= ing to delay the age of marriage.

We have seen marriage delayed for example in and in Indonesia with very significantly positive effects in reducing childbirth. What we al= so see however that with the postponement of marriage a whole new set of probl= ems which heretofore never occurred because you have for the first time an exte= nded time from puberty to marriage with added risk - of out of wedlock births be= come of more of a concern. Certainly if you marry at the age of 12 you don’= ;t have a high out of wedlock birth risk.

What have probably not changed dramatically are sexual behaviours. What has changed is the context in which those behaviours occur.

What we have se= en , and this is of relevance throughout the world, that ethnic minorities are disadvantaged. If you are in Brazil and black= you are disadvantaged if you are American Indian in the united States= you are disadvantaged, if you are an ethnic minority anywhere in the world you have a tendency to be disadvan= taged

What we are seeing today is a rising voice in ethnic minorities throughout the world who are strongly speaking o= ut and in many settings are striking out to claim their rightful portion of the resources of a country, so we have these significant changes.

As we have said we are also seeing = this vast shift to urbanisation, in France Japan, Brazil Columbia, United States= , in many countries almost the entire population live in urban settings , you have cities such as San Palo where twenty million people live = in them, Cairo with an estimated 18 million people so we are seeing the spawni= ng of not just urban centres but of mega urban centres whose size and scope is almost incomprehensible.

With the changes in urbanisation th= ere are a number of very major social changes, one i= s the disintegration of the traditional family. And tradition= al structures. For example in many communities in Africa, marriage does= not exist as it exists for example in the USA or Europe where March 3^{rd
you walk down the aisle and s=
omeone
says you are married, it is much more of a process, it’s a process wh=
ere
sometime around the age of puberty perhaps your parents build you a hut rig=
ht
behind their hut , that makes a lot of sense to me, and you live in the hut=
and
maybe at some point you meet somebody and then at some point maybe dependin=
g on
the society you are going to move into her hut or she is going to move into
your hut. And at some point maybe with childbirth or maybe after a certain
length of time or depending on a pronouncement depending on the society they
say you guys are together now for good, for real and there is some sense of
connectedness. Take that kind of process and put it in an urban setting and=
it
does not work, it falls apart .. and
so it is with many many other issues.}

I said there was a push towards education with the hope that with it would come social and economic benefits that certainly was the promise of many of our grandparents, great grandpare= nts and even parents, but in many countries of the world and particularly in Africa, education is by no means a guaranteed pathway to social and economic benefits because there is not the economic substrate to sustain it, so what= we have is people moving from the countryside to the city in hope of better life ad jobs but what they are le= ft with is rising unemployment and with rising unemployment comes rising viole= nce, you also get suicide and youth suicide is a relatively new phenomenon in developing countries and certainly reflects the changes in developing countries throughout the world.

There are some other consequences of education as well. Clearly there are positive consequences, but one of the things we see is a delay in the age of marriage because as I said before, marriage certainly gets in the way of schooling and what we also see is a r= ise in out of wedlock birth, because of the delay in marriage and the lack of change of sexual behaviours.

And therefore there is a rise in clandestine abortions. It has been estimated in six countries in Latin America that there are approximately 2 mil= lion clandestine abortions per year. In Africa= in six East and South African countries 66% of kids 15-19 years old that we surveyed - that is about 7,000 kids in six countries said that they knew someone who had an abortion.

There is a wide range of abortions = that are clandestine abortions that range from absolutely illegal, insanitary to where in some countries even though ill= egal there is a high tolerance of abortion it is estimated that abortions account for 40 to 50 percent of all maternal deaths in countries where they are ill= egal because of haemorrhage and sepsis and the other thing which holds good for abortions as for HIV and Aids is that it is a phenomenon of those who are in school and have high hopes, hence it is wiping out the intelligentsia. It is wiping out those who have completed their schooling, who have completed their university because it is those who are in the cities who are delaying their marriage and are at grea= test risk for these conditions.

Let us touch on trends for mortality and morbidity. For both industrialised countries, and for developing countr= ies what we are seeing clearly is a convergence of issues around mortality unintentional injuries, suicide, homicide and maternal mortality are really= the major causes of death in nearly every country of the world but when we look= at mortality trends there are a number of countries where we have data that ca= lls for some level of optimism. In the decade 1980/1990 we saw a 13% decline in mortality in the second decade of life in the United States= , I should also say that it was not evenly distributed For American white males= we saw a decline of 17%. Among African American black males we saw an increase= in mortality of 11 % so while we see this overall trend - it is not even.=

There is a decline in Latin America of 3.5% and 7.5% in France so there seem to be some general trends that are pointing in a positive direction. Some of the things that we see as the causes of these trends is the declining mortality in vehicular deaths. Between 1986 and 1992 in the USA we saw a 38% decline in vehicular deaths. Another is that the primary cause= s of mortality remain unintentional injury, homicide, suicide war and males are = 2 to 4 times more likely to die than females during adolescence and this is true= in every single country where we have been able to look at it.

Mortality declines from birth to 14 years of age and then begins to rise at 15 years of age and beyond when the= re is a disproportionate increase in deaths in males and this all suggests behavioural factors are responsible.

When we look at suicide what we see during the decade of&n= bsp; the eighties is that most countries there has been a dramatic increase. In some countries and particularly those where there has been a dramatic social change the rates are particularly high - and where there has been political upheaval we continue to see this through the nineties, the previous Soviet Union, the changes with the fall of communism , dramatic in= creases in suicide and homicide, interestingly countries that had a decline in the = 80s such as Czechoslovakia and Hungary and for some reason Venezuela, in the la= st ten years have had a dramatic rise in suicide. Particularly in eastern European countr= ies.

Traditionally countries that have h= ad a lower rate have been the Mediterranean= , Latin America= and the Muslim countries and Saharan Africa. There is certainly a religious bias that becomes a reporting bias but even so the rates are lower. <= /span>

Industrialised countries of = Europe, the pacific basin and the far east have the high= est rates. I think that these data underscore a very important perspective for = us - we tend to think of ourselves as developed and of poor countries as undevel= oped but a measure of social stress and community angst is suicide and certainly= many in poorer countries look at what is going on in the industrialised world and ask is this really what we want - is this the end product that we are aiming for. In the industrialised world we have paid a very high price for the soc= ial changes and the economic benefits that we sustain.

Some of the factors which influence suicide rates include the sort of social changes we have been looking at. Main influences include - unemploy= ment, dual parent employment, divorce rate which has gone up many fold to over 50= % in the USA, high homicide rates, alcohol use rising, this whole set of patterns and secularisation of society. This is a issue which= is hotly debated in the and very much politicised but the reality is that belief is protective - it= is protective on an individual level and it is protective on a society level.<= span style=3D'mso-spacerun:yes'> We also should note social disrupt= ion, overcrowding, urban stress societal norms that sanction it - such as some countries in the east.

As I indicated maternal mortality is one of the major causes of early death and 50% of maternal deaths are due to abortion complications another set of problems that are more prevalent in y= oung women are cephalo-pelvic disproportion and ritu= al mutilation causing disproportion, haemorrhage, toxaemia and sepsis.

Finally what we are seeing in eastern Europe is that at least 25% of maternal deaths= are due to abortion. This is surprising given the tradition that in eastern Europe there was not ready availability of contraception and abortion was an accepted method of limitation of birth ra= te and the prime contraceptive method in many countries, in Russia for example.

When we look at issues relating to violence and homicide it used to be said that in the United States= had a disproportionately high rate of homicide. The USA has a higher rate of juvenile deaths from violence than the other 25 industrialised countries put together. Other areas are also seeing rises in violence - Columbia 28% - Jamaica street gangs etc.

In the new Independent Eastern Euro= pean states homicide violence accounts for 80o% of the excess mortality. Increas= e in violence is a major global issue, access o weapons is increasing around the world and access to drugs also. Drugs that used to be export drugs in poor countries are increasingly being used locally also and this is associated w= ith increasing violence.

When we look at morbidity we must a= lso consider HIV infection. Seropositivity is incre= asing significantly. Age of sexual debut is falling in El Salvador= 40% report having had sex by age 15. In Spain 45%, in about half the population, in North America and Europe 40-60% the trends of sexual debut do not vary vastly from one region to another. What we have is some variability within regions and certainly there are areas that are significant exceptions - for example the Muslim countrie= s, Japan have much different ages of sexual debut although even there it is declining. =

What does vary significantly though= is birth rate from 2/1000 in Japan to= 59/1000 in the . However although one can say that Japan varies because of the late age of sexual debut, the same cannot be said for Denmark, the Netherlands or UK wh= ich have a lower rate than the USA so what must be different is contraceptive behaviour.

One of the consequences which we are likewise seeing in countries around the world that are willing to look at i= t - is the rise in out of wedlock births - in the USA we saw a rise from 10% to= 76% from 1960 to the present and interestingly in a paper that is just about to= be published out of Chile it was identical&nb= sp; and so these trends that we are seeing are not unique to a single population - one of the things that is occurring which I think is very significant - those who are from Europe in North America - your grandmother= or great grandmother had how many children? I hear in the back of the room 10 - 9 five was a small fami= ly - 10, 9, 14 was common in the United States at the turn of the century - we h= ave gone from that size family - think about it - is there a person here in the United States - anyone who knows a family with 12 children today? It is not= in our frame of reference - but it was in grandma’s frame of reference. = In two generations we have shrunk our family sizes. The first significant chan= ge is not a change of behaviour but a change of desire - and what we have seen= is a change of desire of what is the normal family size. People, women want smaller families and I would suggest men want smaller family sizes as well.= The reasons are economic families 1975 - 1985 the ideal family size shrunk by as much as a third. - based on family fertility data. Contraception continues = to rise and there is a growing awareness of contraceptive alternatives. People want smaller families, contraceptive awareness in Kenya Thailand Brazil - in small rural villages - where there are 90- 95% of young people aware of contraception - I am amazed there is that level of awareness. Clearly behaviour and use of contraception lags behind.

There are many reasons for this the barriers to contraception - clearly one is cost and in many countries the c= ost of a months supply is $22 - in Brazil $3; Israel $6; $3/4 Mexico Argentina = $11 very expensive - and even if you take $3/4 per month kids whose income may = be selling the odd cigarette on the street - that may be al= they make and so the possibility of using these kinds of methods may be extraordinarily prohibitive. Barrier methods too - in Russia - local made condoms break whereas western condoms cost a lot more.

There are many legal barriers also = for adolescents or unmarried women to obtain contraceptives. Medically we shoul= d be looking at safeguarding women over the age of 35 from the side effects but = over the counter use of oral contraceptives for young women makes very good sens= e.

Cultural issues also involve the st= ress between cultural groups when one uses contraception more than the other and= may be worried about dwindling population - example was given from the audience= by Indian delegate regarding Hindu / Moslem issues. The focus is on population reduction and whether it is race or culture within countries or contracepti= ve ‘imperialism’ these are major issues there are many examples of programmes that are very culturally sensitive and are grounded in the local community that are very sensitive and respond to local issues rather than a political agenda.

Alcohol and drug use - 47% of fourth graders in (about 16 years old) use alcohol. In the USA we have seen a decline in heavy drinking and this decline has continued thr= ough 1996 data .

Let us pull some of these threads together - there are some common issues. How do we ground our programmes in= the community to serve local need and be effective?

There have been a generation of projects and programmes that look at what works and what does not - almost every problem focused intervention fails - the data in all focused interventions is terrible. Look at a few in the USA that have had high leve= ls of publicity - DARE - on drug abuse prevention - repeatedly shown to be an ineffective agency. Scared Straight - in the late 80 as a wonderful violence prevention strategy - ineffective . Christian Mo= ore came out last year with a two volume analysis of teen pregnancy prevention programmes and she concludes that maybe , maybe six programmes work - that = is not many given the number of programmes and the hundreds of millions of dol= lars invested. We know we must formulate more effective programmes, we know that= if we take any risk factor, we can improve the outcomes for kids, we know that there is no discrete risk factor for discrete problems and the most effecti= ve programmes are those that strengthen families, improve education and provide economic opportunities= and there are some terrific examples, terrific examples from = the poorest communities across the world. One in Argentina where a guy started = to work with homeless kids and getting them to paint buildings and he started tying their work into school - they had to go to school and then work - they got money and education. In Chile a baker did the same thing. In a guy went to his elementary school and said he would support every kid who would stay in school. \they say if = we support you in this way - then the other problems will diminish. These prog= rammes have something in common - they know how to provide a connectedness. We know from a decade of research that establishing social bonding - the ‘connectedness’ that links people to each other is the number one most important t= hing that protects young people from harm. Kids that feel connected to adults are protected from harm. Sure every drug dealer in the world knows the principl= es of social bonding. A guy is standing on the street corner and a ten year old comes by and he says -= .. ‘I want you to go across the street and deliver this package and come back to em and I’ll give you money’. … <= span class=3DGramE>he makes a successful trip - using his skills and the = man says - you did a great job , = come round again and do some more things for me. This dealer provides opportunity for participation and active involvement , teaches skills for participation= - this dealer did not give the kid a task which was beyond him, he gave him something which was appropriate to his level - he did not give him 15 packa= ges and a list - he gave one package at a time, just perfect for a ten year old, and there was recognition and there was reward for a job well done - that is how we create a sense of connectedness of kids with each other and kids with the community.

Optimally interventions need to be multi system, involving family, school , community, they need to be based o= n a set of principles which focus on known risk factors, interventions based on what is known to work and frequently there is a political compulsion to inv= est in things which we know don’t work. We are about to embark in this country , perhaps because we have far too much money, on a two hundred mill= ion dollar investment in teen pregnancy prevention under the name of abstinence only education which we know does not work, it has been demonstrated not to work, and yet we will do it anyway. We institute DARE programmes in school after school all over the country even though we know it does not reduce dr= ug use and we still propagate school clinics knowing that they do not reduce school pregnancy.

We must base our interventions on w= hat we know will work, we must focus on risk factors but also on protective fac= tors and we must intervene early before behaviours stabilise. I would propos= ed a model for thinking through an approach. Young people’s service need four factors in order to be successful - 1 - you need an = adult , one they can trust, who cares and with whom they can feel connected. 2 - They need the opportunity to make a contribution - we talk about youth involvement and participation - but it is important because the opportunity to give to your community provides a source of connectedness. 3= - Kids need activities, community, school opportunities again for connection = - 4 - a place to hang out,= a safe place where there is an adult - a village playing field where adults on a volunt= eer basis perhaps make sure it is safe e t c these four elements are needed for young people - they are not costly and would make sure that a decade from n= ow we would not still be looking at worsening trends.