EDITORIALS
all who dabble in screening. 4-6 As a good general rule, a screening program can only be justified if the disease sought can be identified unequivocally; if effective treatment is available for the "cases" so found; and, above all, if the treatment is really necessary. Were such criteria strictly applied, I daresay that very few mass screeners would be left to roam free.
ABRAHAM B. BERGMAN, MD Address reprint requests to Dr. Abraham B. Bergman, Director, Outpatient Services, Children's Orthopedic Hospital and Medical Center, Box C-5371, Seattle, WA 98105. Dr. Bergman is also Professor of Pediatrics and Health Services, University of Washington.
REFERENCES 1. Matanoski, G. M., Henderson, M. M., Stine, 0. C., et al. Evaluation of screening program for heart disease. Am. J. Public Health, 67:609-611, 1977. 2. Bergman, A. B. and Stamm, S. J. The morbidity of cardiac nondisease in school children. New Eng. J. Med., 276:1008-1013, 1966. 3. Hampton, M. L., Anderson, J., Lavizzo, B. S., Bergman, A. B. Sickle-cell "nondisease", a potentially serious public health problem. Amer. J. of Dis. of Child. 128:58-61, 1974. 4. Wilson, J. M. G., Junger, G. Principles and practice of screening for disease. World Health Organization, Geneva, 1968. 5. Galen, R. S. and Gambino, S. R. Beyond normality-the predictive value and efficiency of medical diagnoses. John Wiley and Sons, New York, 1975. 6. Whitby, L. G. Screening for disease-definitions and criteria. Lancet, 2:819-821, 1974.
Child Maltreatment, Family Stress, and Ecological Insult The well-being of the child, growth and development in a healthy organism, is a universal aspiration concerned with the establishment and guidance of the next generation. National concerns tend to fragment this universality by introducing an ideology, political structure, economic system, socialization pattern, and a value system. Yet these factors, in conjunction with the physical environment, form the ecological womb in which the child is nurtured by the family. Both family and child live in this ecological space. Although the family attempts to protect the child from insults, this protection may manifest itself in maltreatment of the child under severe economic and social conditions. During the first quarter of this century, much attention was paid to the exploitation of children. Such concerns have all but vanished today except for migrant children and a small number of children exploited in the interests of pornography. However, over the last two decades, concerns and social action relating to the maltreatment of children have been increasing: the health care system has been primarily concerned with abuse, failure to thrive, accidents, and poisonings, while the social service system has dealt primarily with neglect and protective care as aspects of general child welfare. In 1962 the U.S. Children's Bureau developed and promoted a model state child abuse mandatory reporting law. The National Center on Child Abuse and Neglect was established in 1974 within the Bureau for the implementation of the Child Abuse Prevention and Treatment Act of 1974. In this issue of the Journal one of the studies supported by the Bureau is reported by the staff of the Family Development Study, Children's Hospital Medical Center, Boston, Massachusetts.I The report describes the development and implementation of a program of family advocacy as a means of dealing with the current problems of families involved in 602
some form of maltreatment of the child-whether it be neglect, abuse, failure to thrive, accidents, or poisonings. These "social illnesses" which are labeled "pediatric social illness" by the authors of this report provide a broader and more dynamic definition than does the more limiting label "the battered child syndrome" developed by C. Henry Kempe and used very successfully to arouse the country to the existence and plight of children involved in child abuse.2 These investigators are acutely aware of the ecological stresses that affect the family and contribute to a host of problems including the maltreatment of children. The researchers use lay staff in the provision of services: one calls them "lay therapists"2 and the other "advocates"' and they are used for different purposes as the titles imply. However, both Kempe and the Harvard group deny that what the lay staff does is social work or social casework. Both are wrong, probably for a similar reason-a restricted perception of their approaches to the maltreatment of children. Social work is an occupational specialty, a profession, whose function is to enable individuals to develop their capacities fully in the actualization of their social roles in the personal, familial, or group context.3 This may be accomplished through direct services or through a focus on institutional change which significantly alters the ecology. Social work is the clinical application of the knowledge and theory emanating from sociology, economics, psychology, and child development. Furthermore, like the maternal and child health concepts in public health, social work is not restricted to those children and families experiencing maltreatment in the legal sense; it intervenes in all situations in which ecological insult threatens the family and its members. Why then is there this persistent and meticulous attempt by creative social pediatricians to distance themselves from social work? Does it reflect, perhaps, a symbolic representaAJPH July, 1977, Vol. 67, No. 7
EDITORIALS
tion of a limited conceptual framework for intervention rather than a denigration of social work? There are numerous studies relating ecological stress factors to the maltreatment of children.4' 5 The litany of factors is long, the studies are not consistent, the samples are selective and generally biased because their subjects are families known to agencies. Some of the factors are being used to develop predictive scales that will identify high-risk families for primary prevention. Other attempts at prediction use the community as the target group, a useful approach for planning and the allocation of resources. Despite all the serious limitations, the respective investigators are in agreement that environmental stresses, social stresses, and intra-familial interactional patterns combine in some fashion with psychological factors to produce a general, and usually chronic, condition of abuse, neglect, or some other form of child maltreatment. This interactional or ecological model differs very little from the approach to other social problems including the extensive studies relating to delinquency, births-out-of-wedlock, marital incompatibility, the broken family, mental retardation, infant mortality, malnutrition, and venereal disease.3 The reasoning is tautological and it matters little whether the label used-social illness-reflects the evidence or the evidence reflects the label. No one is saying that the maltreatment of children is purposeless, without cause, or without consequences. It is improbable that a definitive set of causes to explain the maltreatment of children will ever be found, and the costly pursuit of such a goal is questionable. There are many forms of child maltreatment; the definitional boundaries are not precise nor do the various categories occur in isolation or independently. This provides a dilemma not only for the social scientists but also for those involved in primary, secondary, and tertiary prevention. How does one prevent a problem whose causes are multiple, ambiguous, and at times beyond the competence of the service providers? Can social illness be treated as somatic illness or is there an implicit suggestion that consideration be given to social treatment? Which "organism" is in need of treatment? The child? The family? The social system? The environment? Some combination of these? The pediatric service becomes involved because of what happened or may happen to the child, not because of what happened or may happen to the family. There are no mandatory reporting laws for the abused or neglected family, nor for individuals 18 years or older (in some states the limit is 21 years). This makes little sense as child maltreatment does not occur in adequately functioning families. Currently, the family becomes the focal point for intervention solely in the interests of the child; if the social illness is not pediatric the family is left to itself or to some other community resource. All the efforts at early identification of high-risk families (mostly mothers) are concerned with the child-rearing competence, the potential behavior of the mother in the parenting role. No matter the inadequate income, the social isolation, the fractured emotional entanglement with other adults, the familial violence, the concern for the mother and the family is muted unless the child is threatened. This reduces AJPH July, 1977, Vol. 67, No. 7
significant social issues to relatively narrow concerns about child rearing. The services have "developmental" childrearing as their ultimate goal. There are sincere efforts to treat the child's trauma and to teach the family other means of coping with stress. Desirable as these are, the intervention efforts fail to deal with the ecological insult to the family and its threat to the well being of all its members. Haggerty brings this issue to the forefront with his studies linking family stress to illness.6 Gelles and others have shown that child abuse is but a part of family violence.7 It is the ecological insult to the family that is the central issue. The child suffers when the family is dysfunctional. Child maltreatment is only one of many symptoms of impaired family functioning. Addressing this issue requires knowledge and skills not generally found in maternal and child health programs. Perhaps it is the reluctance to deal with the significant ecological issues affecting the family that leads to the use by the health services of social worker surrogates who lack the training, experience, and orientation necessary for effective action. The use of lay staff to deal with the ecological impact upon the family is a denial of its importance. Although trained social workers are used as members of the "multidisciplinary team" their role is limited to the clinical functions of the services and the articulation of the social aspect of the illness is attenuated. Public health provides a framework to deal with social illness, to alter the ecology, to make constructive use of all the necessary disciplines. The hierarchial medical model had its time and place; it is dysfunctional in dealing with social illness. Two models for dealing with comprehensive services for child maltreatment are emerging: a health oriented model, usually as part of a hospital's pediatric department; and a social service model, usually the protective care unit of a public social service agency. Both are necessary, yet both need to broaden their conceptual framework and place greater emphasis upon the family as the critical unit in the treatment program. These two powerful community institutions working with the entire family must do more than improve the coping ability of families, an approach which implies that the ecological stress factors are accepted. By working together within a public health framework they can each broaden the other's approach to pediatric social illness, balancing the attention given to physical traumas with the psychological and social traumas experienced by families in the process of child-rearing and altering for the better the ecology of families subject to insult.
CHARLES P. GERSHENSON, PHD Address reprint requests to Dr. Charles P. Gershenson, Special Assistant for Research, Children's Bureau, Office of Child Development, Box 1182, Washington, DC, 20013. The views expressed above are those of the author and do not
reflect the policies or views of the Children's Bureau or Office of
Child Development.
REFERENCES 1. Morse, A. E., Hyde, J. N., Jr., Newberger, E. H., and Reed, R. B. Environmental correlates of pediatric social illness: pre-
603
EDITORIALS
2.
3. 4.
5.
ventive implications of an advocacy approach. Am. J. Public Health 67:612-615, 1977. Kempe, C. H. and Helfer, R. E. Helping the Battered Child and His Family, Philadelphia, PA: J. B. Lippincott Co. 1972. Cohen, N. E., Ed. Social Work and Social Problems, New York: National Association of Social Workers, Inc., 1964. Polansky, N. A., Hally, C., and Polansky, N. F. Profile of Neglect. A Survey of the State of Knowledge of Child Neglect. DHEW, (SRS) 75-23037, 1975. Dohrenwend, B. S., and Dohrenwend, B. P., Eds. Stressful
Life Events: Their Nature and Effects, New York: John Wiley & Sons, 1974. 6. Haggerty, R. J., Roghmann, K. J., and Pless, I. B. Child Health and the Community, New York: John Wiley & Sons, 1975. 7. Gelles, R. J.,"Violence toward Children in the United States," paper presented at the American Association for the Advancement of Science Annual Meeting, Denver, CO, 1977. (To be included in a forthcoming book by Murray A. Straus, Richard J. Gelles, and Suzanne K. Steinmetz, Violence in the American Family.)
Abortions and Public Policy The feelings unleashed following the United States Supreme Court's sanction of abortions in 1973 have spanned a breadth of controversy equaled by few issues in our times. Legal, medical, ethical, religious and political-almost every branch of the human endeavor is impelled to respond. Within a given field the opinions voiced may possess common terms of reference, but their verdicts are divergent. One may hazard the guess that they reflect individual human experience rather than immutability. The derivation of the word abortion is from a language root that signifies the disappearance of sun and moon, primitive symbols of life on earth. It would be a mistake to underestimate the depth of the emotions involved in the controversy around it, or to override one side or the other with the rhetoric of advocacy. One extreme hides the gas chambers efficiently disposing of cripples and Jews. The other masks the self-righteous denial of a health service to those who desire it. In this charged atmosphere, factual information which can shed light on public policy is rare. The Journal publishes two studies which supply such information in its current issue.1, 2 Analyzing data from President Jimmy Carter's home state, Shelton addresses himself to the provocative question of whether abortion or contraception has lowered the fertility of girls 14 years or less of age. In 1972 a Georgian law allowed minors to obtain contraceptive advice without parental consent. However, the fertility rate of Georgian teenagers under age 15, which had begun to rise in 1967, continued to do so through 1973. It declined slightly in 1974 for the first time in 6 years. In 1975 the decline was quite sharp. It was greatest among whites and residents of Central Atlanta. Shelton traces this recent decline to the delivery of abortion services rather than contraceptive services, basing his case on the timing of the decline and on differences in geographic accessibility and the reported utilization of abortion and contraceptive services. It is of some interest that no racial differential in the utilization of abortion services exists for older women in Georgia. In the late 1960s comprehensive service programs of prenatal, maternity, and newborn care for school-age moth604
ers were developed in many urban communities. New Haven, Connecticut was the site of one of the oldest and best known. Serving high school students 17 years or under, the Yale program included a heavy increment of counseling and education encouraging the use of contraception. In a followup of a group of 180 adolescents served by this program 6-8 years after their babies were born, Jekel, Tyler and Klerman found, somewhat to their surprise, that over one-third of them had used legal abortion to terminate some 80 subsequent pregnancies; an additional 16 young women had sought and received surgical sterilization. The abortion experience after the first pregnancy of the 180 teenage mothers served by this special program was not significantly different from comparable groups of teenage mothers who had not been served by the program. The figures reported by Jekel and his colleagues almost certainly understate the situation since they are based on a review of medical records at the Yale-New Haven Hospital and thus do not include abortions or sterilizations performed elsewhere. Both of these studies, it should be noted, reflect the fact that applying a little imagination to the extraction of data from routine records and statistical reporting systems, canif one understands the limitations of the data-yield useful and important information. This simple but often neglected area of research has been commented upon before in these pages .3 In 1975 there were 12,642 births to young women under the age of 15 in the United States, about the same number as in 1974.4' 5 Few of us would be bold enough to maintain that many children in today's world can function as mothers at the age of 13 or 14, or that the children of such children can be nourished by the social milieu into which they are born or accommodated by an already overloaded adoption process, if it were to be chosen. Few of us, including the authors of these two papers, would maintain that the taking of life after its conception is preferable to avoidance or prevention of conception in situations inimical to life. The evidence from these two studies, however, indicates that we do not understand enough about human behavior or that we have not matured enough as a society to apply what we know to be able AJPH July, 1977, Vol. 67, No. 7
all who dabble in screening. 4-6 As a good general rule, a screening program can only be justified if the disease sought can be identified unequivocally; if effective treatment is available for the "cases" so found; and, above all, if the treatment is really necessary. Were such criteria strictly applied, I daresay that very few mass screeners would be left to roam free.
ABRAHAM B. BERGMAN, MD Address reprint requests to Dr. Abraham B. Bergman, Director, Outpatient Services, Children's Orthopedic Hospital and Medical Center, Box C-5371, Seattle, WA 98105. Dr. Bergman is also Professor of Pediatrics and Health Services, University of Washington.
REFERENCES 1. Matanoski, G. M., Henderson, M. M., Stine, 0. C., et al. Evaluation of screening program for heart disease. Am. J. Public Health, 67:609-611, 1977. 2. Bergman, A. B. and Stamm, S. J. The morbidity of cardiac nondisease in school children. New Eng. J. Med., 276:1008-1013, 1966. 3. Hampton, M. L., Anderson, J., Lavizzo, B. S., Bergman, A. B. Sickle-cell "nondisease", a potentially serious public health problem. Amer. J. of Dis. of Child. 128:58-61, 1974. 4. Wilson, J. M. G., Junger, G. Principles and practice of screening for disease. World Health Organization, Geneva, 1968. 5. Galen, R. S. and Gambino, S. R. Beyond normality-the predictive value and efficiency of medical diagnoses. John Wiley and Sons, New York, 1975. 6. Whitby, L. G. Screening for disease-definitions and criteria. Lancet, 2:819-821, 1974.
Child Maltreatment, Family Stress, and Ecological Insult The well-being of the child, growth and development in a healthy organism, is a universal aspiration concerned with the establishment and guidance of the next generation. National concerns tend to fragment this universality by introducing an ideology, political structure, economic system, socialization pattern, and a value system. Yet these factors, in conjunction with the physical environment, form the ecological womb in which the child is nurtured by the family. Both family and child live in this ecological space. Although the family attempts to protect the child from insults, this protection may manifest itself in maltreatment of the child under severe economic and social conditions. During the first quarter of this century, much attention was paid to the exploitation of children. Such concerns have all but vanished today except for migrant children and a small number of children exploited in the interests of pornography. However, over the last two decades, concerns and social action relating to the maltreatment of children have been increasing: the health care system has been primarily concerned with abuse, failure to thrive, accidents, and poisonings, while the social service system has dealt primarily with neglect and protective care as aspects of general child welfare. In 1962 the U.S. Children's Bureau developed and promoted a model state child abuse mandatory reporting law. The National Center on Child Abuse and Neglect was established in 1974 within the Bureau for the implementation of the Child Abuse Prevention and Treatment Act of 1974. In this issue of the Journal one of the studies supported by the Bureau is reported by the staff of the Family Development Study, Children's Hospital Medical Center, Boston, Massachusetts.I The report describes the development and implementation of a program of family advocacy as a means of dealing with the current problems of families involved in 602
some form of maltreatment of the child-whether it be neglect, abuse, failure to thrive, accidents, or poisonings. These "social illnesses" which are labeled "pediatric social illness" by the authors of this report provide a broader and more dynamic definition than does the more limiting label "the battered child syndrome" developed by C. Henry Kempe and used very successfully to arouse the country to the existence and plight of children involved in child abuse.2 These investigators are acutely aware of the ecological stresses that affect the family and contribute to a host of problems including the maltreatment of children. The researchers use lay staff in the provision of services: one calls them "lay therapists"2 and the other "advocates"' and they are used for different purposes as the titles imply. However, both Kempe and the Harvard group deny that what the lay staff does is social work or social casework. Both are wrong, probably for a similar reason-a restricted perception of their approaches to the maltreatment of children. Social work is an occupational specialty, a profession, whose function is to enable individuals to develop their capacities fully in the actualization of their social roles in the personal, familial, or group context.3 This may be accomplished through direct services or through a focus on institutional change which significantly alters the ecology. Social work is the clinical application of the knowledge and theory emanating from sociology, economics, psychology, and child development. Furthermore, like the maternal and child health concepts in public health, social work is not restricted to those children and families experiencing maltreatment in the legal sense; it intervenes in all situations in which ecological insult threatens the family and its members. Why then is there this persistent and meticulous attempt by creative social pediatricians to distance themselves from social work? Does it reflect, perhaps, a symbolic representaAJPH July, 1977, Vol. 67, No. 7
EDITORIALS
tion of a limited conceptual framework for intervention rather than a denigration of social work? There are numerous studies relating ecological stress factors to the maltreatment of children.4' 5 The litany of factors is long, the studies are not consistent, the samples are selective and generally biased because their subjects are families known to agencies. Some of the factors are being used to develop predictive scales that will identify high-risk families for primary prevention. Other attempts at prediction use the community as the target group, a useful approach for planning and the allocation of resources. Despite all the serious limitations, the respective investigators are in agreement that environmental stresses, social stresses, and intra-familial interactional patterns combine in some fashion with psychological factors to produce a general, and usually chronic, condition of abuse, neglect, or some other form of child maltreatment. This interactional or ecological model differs very little from the approach to other social problems including the extensive studies relating to delinquency, births-out-of-wedlock, marital incompatibility, the broken family, mental retardation, infant mortality, malnutrition, and venereal disease.3 The reasoning is tautological and it matters little whether the label used-social illness-reflects the evidence or the evidence reflects the label. No one is saying that the maltreatment of children is purposeless, without cause, or without consequences. It is improbable that a definitive set of causes to explain the maltreatment of children will ever be found, and the costly pursuit of such a goal is questionable. There are many forms of child maltreatment; the definitional boundaries are not precise nor do the various categories occur in isolation or independently. This provides a dilemma not only for the social scientists but also for those involved in primary, secondary, and tertiary prevention. How does one prevent a problem whose causes are multiple, ambiguous, and at times beyond the competence of the service providers? Can social illness be treated as somatic illness or is there an implicit suggestion that consideration be given to social treatment? Which "organism" is in need of treatment? The child? The family? The social system? The environment? Some combination of these? The pediatric service becomes involved because of what happened or may happen to the child, not because of what happened or may happen to the family. There are no mandatory reporting laws for the abused or neglected family, nor for individuals 18 years or older (in some states the limit is 21 years). This makes little sense as child maltreatment does not occur in adequately functioning families. Currently, the family becomes the focal point for intervention solely in the interests of the child; if the social illness is not pediatric the family is left to itself or to some other community resource. All the efforts at early identification of high-risk families (mostly mothers) are concerned with the child-rearing competence, the potential behavior of the mother in the parenting role. No matter the inadequate income, the social isolation, the fractured emotional entanglement with other adults, the familial violence, the concern for the mother and the family is muted unless the child is threatened. This reduces AJPH July, 1977, Vol. 67, No. 7
significant social issues to relatively narrow concerns about child rearing. The services have "developmental" childrearing as their ultimate goal. There are sincere efforts to treat the child's trauma and to teach the family other means of coping with stress. Desirable as these are, the intervention efforts fail to deal with the ecological insult to the family and its threat to the well being of all its members. Haggerty brings this issue to the forefront with his studies linking family stress to illness.6 Gelles and others have shown that child abuse is but a part of family violence.7 It is the ecological insult to the family that is the central issue. The child suffers when the family is dysfunctional. Child maltreatment is only one of many symptoms of impaired family functioning. Addressing this issue requires knowledge and skills not generally found in maternal and child health programs. Perhaps it is the reluctance to deal with the significant ecological issues affecting the family that leads to the use by the health services of social worker surrogates who lack the training, experience, and orientation necessary for effective action. The use of lay staff to deal with the ecological impact upon the family is a denial of its importance. Although trained social workers are used as members of the "multidisciplinary team" their role is limited to the clinical functions of the services and the articulation of the social aspect of the illness is attenuated. Public health provides a framework to deal with social illness, to alter the ecology, to make constructive use of all the necessary disciplines. The hierarchial medical model had its time and place; it is dysfunctional in dealing with social illness. Two models for dealing with comprehensive services for child maltreatment are emerging: a health oriented model, usually as part of a hospital's pediatric department; and a social service model, usually the protective care unit of a public social service agency. Both are necessary, yet both need to broaden their conceptual framework and place greater emphasis upon the family as the critical unit in the treatment program. These two powerful community institutions working with the entire family must do more than improve the coping ability of families, an approach which implies that the ecological stress factors are accepted. By working together within a public health framework they can each broaden the other's approach to pediatric social illness, balancing the attention given to physical traumas with the psychological and social traumas experienced by families in the process of child-rearing and altering for the better the ecology of families subject to insult.
CHARLES P. GERSHENSON, PHD Address reprint requests to Dr. Charles P. Gershenson, Special Assistant for Research, Children's Bureau, Office of Child Development, Box 1182, Washington, DC, 20013. The views expressed above are those of the author and do not
reflect the policies or views of the Children's Bureau or Office of
Child Development.
REFERENCES 1. Morse, A. E., Hyde, J. N., Jr., Newberger, E. H., and Reed, R. B. Environmental correlates of pediatric social illness: pre-
603
EDITORIALS
2.
3. 4.
5.
ventive implications of an advocacy approach. Am. J. Public Health 67:612-615, 1977. Kempe, C. H. and Helfer, R. E. Helping the Battered Child and His Family, Philadelphia, PA: J. B. Lippincott Co. 1972. Cohen, N. E., Ed. Social Work and Social Problems, New York: National Association of Social Workers, Inc., 1964. Polansky, N. A., Hally, C., and Polansky, N. F. Profile of Neglect. A Survey of the State of Knowledge of Child Neglect. DHEW, (SRS) 75-23037, 1975. Dohrenwend, B. S., and Dohrenwend, B. P., Eds. Stressful
Life Events: Their Nature and Effects, New York: John Wiley & Sons, 1974. 6. Haggerty, R. J., Roghmann, K. J., and Pless, I. B. Child Health and the Community, New York: John Wiley & Sons, 1975. 7. Gelles, R. J.,"Violence toward Children in the United States," paper presented at the American Association for the Advancement of Science Annual Meeting, Denver, CO, 1977. (To be included in a forthcoming book by Murray A. Straus, Richard J. Gelles, and Suzanne K. Steinmetz, Violence in the American Family.)
Abortions and Public Policy The feelings unleashed following the United States Supreme Court's sanction of abortions in 1973 have spanned a breadth of controversy equaled by few issues in our times. Legal, medical, ethical, religious and political-almost every branch of the human endeavor is impelled to respond. Within a given field the opinions voiced may possess common terms of reference, but their verdicts are divergent. One may hazard the guess that they reflect individual human experience rather than immutability. The derivation of the word abortion is from a language root that signifies the disappearance of sun and moon, primitive symbols of life on earth. It would be a mistake to underestimate the depth of the emotions involved in the controversy around it, or to override one side or the other with the rhetoric of advocacy. One extreme hides the gas chambers efficiently disposing of cripples and Jews. The other masks the self-righteous denial of a health service to those who desire it. In this charged atmosphere, factual information which can shed light on public policy is rare. The Journal publishes two studies which supply such information in its current issue.1, 2 Analyzing data from President Jimmy Carter's home state, Shelton addresses himself to the provocative question of whether abortion or contraception has lowered the fertility of girls 14 years or less of age. In 1972 a Georgian law allowed minors to obtain contraceptive advice without parental consent. However, the fertility rate of Georgian teenagers under age 15, which had begun to rise in 1967, continued to do so through 1973. It declined slightly in 1974 for the first time in 6 years. In 1975 the decline was quite sharp. It was greatest among whites and residents of Central Atlanta. Shelton traces this recent decline to the delivery of abortion services rather than contraceptive services, basing his case on the timing of the decline and on differences in geographic accessibility and the reported utilization of abortion and contraceptive services. It is of some interest that no racial differential in the utilization of abortion services exists for older women in Georgia. In the late 1960s comprehensive service programs of prenatal, maternity, and newborn care for school-age moth604
ers were developed in many urban communities. New Haven, Connecticut was the site of one of the oldest and best known. Serving high school students 17 years or under, the Yale program included a heavy increment of counseling and education encouraging the use of contraception. In a followup of a group of 180 adolescents served by this program 6-8 years after their babies were born, Jekel, Tyler and Klerman found, somewhat to their surprise, that over one-third of them had used legal abortion to terminate some 80 subsequent pregnancies; an additional 16 young women had sought and received surgical sterilization. The abortion experience after the first pregnancy of the 180 teenage mothers served by this special program was not significantly different from comparable groups of teenage mothers who had not been served by the program. The figures reported by Jekel and his colleagues almost certainly understate the situation since they are based on a review of medical records at the Yale-New Haven Hospital and thus do not include abortions or sterilizations performed elsewhere. Both of these studies, it should be noted, reflect the fact that applying a little imagination to the extraction of data from routine records and statistical reporting systems, canif one understands the limitations of the data-yield useful and important information. This simple but often neglected area of research has been commented upon before in these pages .3 In 1975 there were 12,642 births to young women under the age of 15 in the United States, about the same number as in 1974.4' 5 Few of us would be bold enough to maintain that many children in today's world can function as mothers at the age of 13 or 14, or that the children of such children can be nourished by the social milieu into which they are born or accommodated by an already overloaded adoption process, if it were to be chosen. Few of us, including the authors of these two papers, would maintain that the taking of life after its conception is preferable to avoidance or prevention of conception in situations inimical to life. The evidence from these two studies, however, indicates that we do not understand enough about human behavior or that we have not matured enough as a society to apply what we know to be able AJPH July, 1977, Vol. 67, No. 7
