Understanding gender roles in teen pregnancy prevention among American Indian youth

Teen pregnancy has major public health ramifcations for teen mothers and their children. For example, teen mothers are less likely to utilize timely prenatal care, increasing the risk for premature birth and low birthweight.1-3 Teen mothers are also less likely to breastfeed,4 which is concerning because breastfeeding has numerous health benefits for both the mother and her baby.5 In addition, young mothers are more likely to drop out of school,6 which holds unfavorable consequences for their long-term financial prospects.7 Teenage pregnancy, therefore, results not only in social costs, but economic costs as well.8 Likely due to prevention efforts and more affordable contraception options, teenage birth rates have fallen to a historic low, and rates of teen pregnancy have generally been decreasing.9,10 However, American Indian and Alaska Natives (AI/AN) teens had the lowest decrease in pregnancy amongst females aged 15-19 in 2012.11 In addition, AI/AN teens had the largest single-year increase in teen pregnancy rates of any racial group in 2007 (rising 7%), a glaring disparity when compared to the 1% increase for non-Hispanic black teens, 2% increase for non-Hispanic white teens and Asian/Pacifc Islander teens, and 2% decrease for Hispanic teens.12 Further, over one-ffth (21%) of AI/AN teen girls will become a mother compared to 16% of girls nationwide.13 Rates of teen birth rates among AI/AN vary by region in the United States, likely due to geographic, ecological, and cultural variation.14 In addition, AI/AN youth likely have higher rates of teen pregnancy because of social and economic disparities, such as poverty,15,16 drug and alcohol use,17-20 and physical/sexual abuse.16,21-23 Evidence also suggests that AI/AN youth initiate sex at earlier ages when compared to other ethnic groups.13 For example, one study of AI youth in Minnesota found that almost 70% of 16-to-18 year-olds and 42% aged 13 to 15 reported they had ever had sexual intercourse,24 compared to a national US study that found 32% of 15-to-17 year-olds had ever had sex.25 Evidence also shows that AI/AN youth are less likely to use contraception when compared to other ethnic groups.11 One national survey with urban AI/AN women ages 15-24 found that 26% had had an unintended pregnancy and 38% had unprotected sex at first intercourse.26 Whereas AI/AN teens have similar knowledge about reproductive health, AI/AN youth between the ages of 18 and 26 were less likely to report using contraception the last time they had sex.13 Perspectives on Gender Given the discrepancies in sexual behaviors by race/ethnicity, understanding potential factors that may exacerbate these differences, such as gender norms and ideologies, is an important direction for prevention research. Gender ideologies, or the socially constructed beliefs regarding how men and women should act, are consistently seen in the social messages aimed at adolescents.27 For example, socially constructed beliefs about femininity often encourage virginity and discourage sexual activity for young women, whereas beliefs about masculinity often encourage the opposite, valuing young men's sexual virility and promiscuity, even if they themselves prefer to be monogamous or abstain from sexual activity.28,29 The impact of gender ideologies is further apparent in contraception decision making and behavior. For example, adolescent females who adhere to traditional female ideologies in upholding sexual abstinence are often encouraged to be passive in their sexual knowledge and behaviors.28 In an attempt not to appear sexual, many girls report that their first intercourse was not planned, hindering their use of any kind of contraception.30 Further deterring the use of contraception is a strong desire for relationship intimacy, often demonstrated through not utilizing contraception in hopes of preventing partners from seeking other sexual outlets.29 In addition, adolescent males are more likely to indicate that using birth control is a woman's responsibility, particularly if they hold to traditional attitudes of masculinity.27,31 These findings suggest the importance of addressing socially-constructed gender norms when examining adolescent contraception use and sexual behaviors. However, to our knowledge, the impact of these gender ideologies has been overlooked for AI youth. Given the disproportionate rates of sexual activity and contraception use in AI adolescents, understanding the role gender expectations have in decisions to have sex and use contraception appears vital. The current study, part of a larger federally funded grant project to develop a community-based teen pregnancy prevention program for AI communities, uncovered the role that gender has on sexual activity and contraception utilization for AI youth. These findings will inform teen pregnant prevention efforts specific to Northern Plains AI youth.