Keywords

7.1 Homelessness Definition and Prevalence

Homelessness is one of the leading social problems in the United States. Various definitions of homelessness describe homeless persons as those who are currently, or have been, living on the street or in a shelter for the past 24 h, who have been staying with friends or family since leaving a permanent residence, or who have no fixed residence (Piliavin, Sosin, Westerfelt, & Matsueda, 1993). However, according to the Stewart B. McKinney Act, 42 U.S.C. § 11301, et seq. (1994), a person is considered homeless who “lacks a fixed, regular, and adequate night-time residence; and…has a primary nighttime residency that is: (a) a supervised publicly or privately operated shelter designed to provide temporary living accommodations…(b) an institution that provides a temporary residence for individuals intended to be institutionalized, or (c) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.” National estimates suggest between 2.3 and 3.5 million people experience homelessness annually (National Alliance to End Homelessness, 2009a).

Adolescents and young adults comprise approximately one-quarter of all people who are homeless (Cauce et al., 2000). Numbering approximately 1.7 million (Molino, McBride, & Kekwaletswe, 2007; Whitbeck, 2009), homeless youth have been defined by federal law (McKinney-Vento Act P.L. 100–628) as “an individual who is less than 21 years of age, for whom it is not possible to live in a safe environment with a relative and who has no other safe alternative living arrangement” (McKinney-Vento Act sec. 725(2); 42 U.S.C. § 11435(c)). Examples of such substandard living situations include staying in shelters, tents, cars, abandoned buildings, motels, bus or train stations, in another person’s house (relative or stranger), or other locations that are not ordinarily used for humans to sleep (McKinney-Vento Act 2001). Other national research suggests that homelessness is not rare among adolescents in the general population, with approximately 8 % of adolescents between 12 and 17 years of age reporting having spent at least 1 night in an emergency shelter, public place, abandoned building, or with a stranger during the previous year (Ringwalt, Greene, Robertson, & McPheeters, 1998).

Homeless youth face many challenging life experiences, and this chapter focuses specifically on this population’s high rates of pregnancy and early parenthood. These are complex topics, as homeless youth s’ complicated circumstances, both prior to leaving home and after becoming homeless, make pregnancy and early parenthood particularly difficult to understand and prevent. This chapter discusses the prevalence and etiology of pregnancy and early parenthood among homeless youth, adverse outcomes associated with homeless youth pregnancy, and opportunities for prevention and intervention services to more effectively promote healthy sexual, reproductive, maternal-child health, and parenting outcomes among homeless youth.

7.2 Becoming Homeless and Surviving on the Streets

Youths’ premature departure from the family home involves varying degrees of independence. Many youth perceive themselves as active agents in the process, choosing to leave undesirable situations for a better life. Others may choose to run away from intolerable situations at home or are motivated to run away to seek more desirable or adventuresome social situations (Lindsey, Kurtz, Jarvis, Williams, & Nackerud, 2000). However, research confirms that running away is often a choice of last resort for adolescents dealing with unbearable situations, such as conflict and maltreatment (Schaffner, 1998).

In contrast to those who leave independently, some youth are pushed out of their homes by parents who force them to leave (Powers, Eckenrode, & Jaklitsch, 1990), or are simply abandoned by parents or other caregivers (Dadds, Braddock, Cuers, Elliott, & Kelly, 1993). “Doubly homeless” youth, who make up an estimated 17.7 % of homeless youth , are those who have been removed from their homes by child protective service authorities and subsequently run away from their foster care placements. Doubly homeless youth report the most problematic family backgrounds (MacLean, Embry, & Cauce, 1999), highest rates of mental health disorders resulting from trauma experienced before and after entering homelessness, and are most vulnerable to abuse and sexual health risks (MacLean et al., 1999).

Once youth become homeless and immersed in “street culture ,” they often develop problematic behaviors as a means of survival. Many homeless street youth become involved in high-risk survival behaviors to earn income to meet their basic food or shelter needs or to finance substance use. Survival behaviors may include prostitution or survival sex (i.e., participating in sexual acts in exchange for money, food, lodging, clothing, or drugs), pimping, pornography, panhandling, theft, selling stolen goods, mugging, dealing drugs, or conning others for goods (Halcón & Lifson, 2004). Survival behaviors are often viewed as necessary due to few formal employment opportunities; formal employment is difficult given the irregular school attendance and high rates of school dropout common among homeless youth (Thompson, Safyer, & Pollio, 2001).

Negative social influences among street youth may encourage youths’ use of survival behaviors, such as panhandling or drug distribution, rather than seeking and engaging in formal employment (Ferguson, Bender, Thompson, Xie, & Pollio, 2012). Homeless youth frequently form street families, who provide each other with protection, emotional support, and material aid (Bao, Whitbeck, & Hoyt, 2000). Youth who feel loyal to their street family may engage in illegal behaviors that secure resources for their peer family and develop street skills that enable them to secure resources and survive.

7.3 Runaway/Homeless Youth Pregnancy

Homeless youth s face a myriad of factors that make life extraordinarily challenging; one such challenge that is of particular concern is pregnancy and early parenthood. Rates of pregnancy among runaway/homeless females have steadily increased during the past three decades, making runaway/homeless females five times more likely to become pregnant than their housed peers (Reeg, Grisham, & Shepard, 2002). National and regional studies report that 30–60 % of female homeless youth indicate past or current pregnancies (Cauce, Stewart, Whitbeck, Paradise, & Hoyt, 2005; Ensign, 2001; Greene & Ringwalt, 1998; Halcón & Lifson, 2004; Haley, Roy, Leclerc, Boudreau, & Boivin, 2004; Milburn, Ayala, Rice, Batterham, & Rotheram-Borus, 2006; Wagner, Carlin, Cauce, & Tenner, 2001; Winetrobe et al., 2013). Many homeless females have been pregnant multiple times (Kilbourne, Herndon, Andersen, Wenzel, & Gelberg, 2002). One study reported 30 % of their sample of homeless young women had been pregnant twice or more (Halcón & Lifson, 2004); another study found that half of homeless women had experienced pregnancy four or more times (Bassuk, Weinreb, Dawson, Perloff, & Buckner, 1997). Clearly, homeless youth represent a high-risk population in regard to pregnancy risk and associated psychosocial consequences; several factors help to explain this risk level.

7.4 The Etiology of Pregnancy Among Runaway/Homeless Youth

The reasons for higher rates of pregnancy, including multiple pregnancies, among homeless/runaway youth are multifaceted (Zweig, Phillips, & Duberstein Lindberg, 2002). Broadly, residential instability interrupts normal adolescent development and is exacerbated by disruption in education, lack of adult caretakers, and exposure to similarly situated homeless peers. At the same time that youth are introduced to these risks, they are often disconnected from traditional supports such as school, family, and society. As a result, pregnant homeless adolescents often have complex profiles consisting of a constellation of high-risk individual characteristics, health-compromising behaviors, and poor family functioning (Greene & Ringwalt, 1998; Haley et al., 2004; Sheaff & Talashek, 1995). In understanding why homeless youth become pregnant, a number of specific risk factors have been identified.

Risky Sexual Behaviors . Compared to non-homeless youth, homeless/runaway adolescents report elevated rates of engagement in risky sexual behaviors. In addition to engaging in higher rates of sexual activity (Carlozzi & Long, 2008), with 95 % of homeless females reporting they are sexually active (Nyamathi, Bennett, Leake, Lewis, & Flaskerud, 1993), homeless youth are also more likely to begin sexual relationships at an earlier age and engage with multiple sexual partners (Greenblatt & Robertson, 1993; Solorio et al., 2008).

Furthermore, homeless youth are likely to engage in unprotected sex. Among homeless youth, contraception and condom use is met with ambivalence, inconsistency, and infrequency (Anderson, Freese, & Pennbridge, 1994; Haley et al., 2004; Solorio et al., 2008; Wagner et al., 2001). One study (Gelberg, Browner, Lejano, & Arangua, 2004) noted that 42 % of sexually active homeless women reported not using any form of birth control during intercourse during the previous year. Of those who did use contraception, condom use was most common; however, only one-third used condoms consistently (Gelberg et al., 2004). Contraceptive use may depend, in part, on the type of sexual partner; homeless women with multiple partners are twice more likely to use contraceptives than women in stable relationships (Gelberg et al., 2008). Similarly, among street youth, only 30 % of females reported using condoms during their most recent sexual encounter. In addition, 40 % noted that using condoms was less likely to occur with regular sexual partners than with casual partners (Anderson et al., 1994).

Homeless youth may face barriers to contraception use. Being homeless may impair one’s access or capacity to practice effective birth control (Gelberg et al., 2008; Hathazi, Lankenau, Sanders, & Jackson Bloom, 2009). The expense and consistency required for effective use of contraceptives is often prohibitive for young women who are homeless. As it is difficult for many young females to use birth control correctly and consistently, youth who live on the streets experience even greater challenges. For those who have lived on the streets for longer periods of time, the risk for adolescent pregnancy is significantly higher than for newly homeless youth (Haley et al., 2004), likely due to these various risky sexual behaviors.

Sexual risk behavior also occurs in the context of survival sex—exchanging sex for food, clothing, and shelter. Homeless youth often have few legal means to earn sufficient money to meet their basic needs and many homeless youth view engagement in survival sex as one of their only viable options for survival on the streets (Anderson et al., 1994; Halcón & Lifson, 2004; Warf et al., 2013). With 10–50 % of homeless youth engaging in survival sex (Greene, Ennett, & Ringwalt, 1999; Halcón & Lifson, 2004; Haley et al., 2004; National Alliance to End Homelessness, 2009b; Warf et al., 2013), it is particularly concerning that as many as 64 % of respondents reported inconsistent or no contraceptive use during survival sex (Warf et al., 2013). Not all homeless youth engage in survival sex; those who are depressed, have friends who trade sex for money/other resources, and are propositioned to trade sex are more likely to engage in this behavior (Tyler & Johnson, 2006). Engaging in sex work as a means of income and survival on the streets introduces homeless youth to a host of negative consequences in addition to pregnancy, including suicide attempts (Greene et al., 1999; Walls & Bell, 2011; Warf et al., 2013; Whitbeck, 2009), robbery, assault, and arrest for prostitution (Warf et al., 2013), and sexually transmitted infections (Lankenau, Clatts, Welle, Goldsamt, & Gwadz, 2005).

It should be noted that the sexual risk taking described here not only places youth at risk for pregnancy but also for contracting HIV and other STIs (Clatts, Goldsamt, Yi, & Gwadz, 2005; Gangamma, Slesnick, Toviessi, & Serovich, 2008; Kral, Molnar, Booth, & Watters, 1997; Solorio et al., 2008; Zimet & Sobo, 1995), with 23–46 % of homeless youth having at least one STI (Rew, 2001). Indeed, the two problems are interrelated; youth who report having a sexually transmitted disease (STD) are more than twice as likely to report a pregnancy compared to those without STDs (Halcón & Lifson, 2004). Thus, risky sexual behaviors of homeless youth may lead to a wide array of dire health consequences.

Substance Use . Homeless youth report twice as much drug use as housed adolescents (Slesnick, Bartle-Haring, Glebova, & Glade, 2006), with national data from the Runaway/Homeless Youth Management Information System (RHY MIS) indicating that most youth reported that, in their lifetime, they had smoked cigarettes (78 %), drank alcohol (76.2 %), or smoked marijuana (98.8 %) (Thompson, 2004). While youth may initiate use prior to running away, many increase their use as they are exposed to various social situations and traumatizing experiences on the street (McMorris, Tyler, Whitbeck, & Hoyt, 2002).

Drug and/or alcohol abuse are often viewed as a “normal” practice on the streets, where homeless youth use substances as a coping mechanism. Not only do homeless youth often have more favorable attitudes toward drug use (Fors & Rojek, 1991) leading to use when socializing, but they also report using substances to cope with trauma experiences and to numb their emotions (Bender, Thompson, Ferguson, Yoder, & Kern, 2013). Thus, although drugs provide a means of escape from the physical and emotional difficulties associated with surviving on the street (Zlotnick, Tam, & Robertson, 2003), the results thwart discerning and forward thinking attitudes, with problematic results.

This high level of substance use and abuse has been shown to be a risk factor for pregnancy among runaway/homeless youth. Many homeless youth report engaging in substance use prior to sexual relations (Hathazi et al., 2009; Solorio et al., 2008). The combination of using drugs/alcohol and engaging in risky sexual behaviors significantly increases the likelihood of pregnancy (Ruttan, Laboucane-Benson, & Munro, 2012), as these youth report having sex while intoxicated, inconsistently use contraception, and are more likely to report multiple sex partners (Rotheram-Borus, Para, Cantwell, Gwadz, & Murphy, 1996; Solorio et al., 2008; Thompson, 2004; Thompson & Pillai, 2006).

Street Victimization . Sexual victimization is unfortunately quite common among homeless youth. Females are more likely to become victims of sexual assault and exploitation while males are more likely to become victims of physical violence (Janus, Archambault, Brown, & Welsh, 1995; McCormack, Janus, & Burgess, 1986; Rew, Taylor-Seehafer, & Fitzgerald, 2001; Whitbeck & Simons, 1993). Specifically, males are more often victims of physical threats and assault, while females experience sexual exploitation, assault, and rape (Stewart et al., 2004). One study found that 37 % of homeless youth participants had been sexually victimized since being on their own (Tyler, Hoyt, Whitbeck, & Cauce, 2001). Another study reported 36.6 % youths were propositioned for sexual favors and 20.7 % were sexually assaulted while on the streets (Terrell, 1997).

Familial maltreatment (physical abuse, sexual abuse , and neglect) by families of origin has been shown to increase the risk of youths’ victimizations once on the streets (Whitbeck, Hoyt, & Ackley, 1997a). Physically abused adolescents are significantly more likely to be assaulted on the streets than adolescents who were not abused by their families (Hoyt, Ryan, & Cauce, 1999; Ryan, Kilmer, Cauce, Watanabe, & Hoyt, 2000). Other known factors contributing to increased victimization include economic deprivation, involvement with delinquent peers, longer periods of time spent on the streets, and engaging in survival sex (Baron & Hartnagel, 1998; Tyler et al., 2001; Whitbeck & Simons, 1990; Yoder, Whitbeck, & Hoyt, 2003). These same risk factors are also strong predictors of early and unplanned pregnancies among runaway/homeless youth.

Frequent experiences of childhood maltreatment and related sexual victimization on the streets increase homeless youth’s pregnancy risk (Stewart et al., 2004). In one study, past sexual abuse was a significant predictor of pregnancy among a sample of homeless young women (Haley et al., 2004). A greater proportion of those who experienced familial incest or stranger sexual abuse also had more than one perpetrator and were likely to have been pregnant during their lifetime. Haley et al. (2004) found 40 % of pregnant homeless young women had experienced familial abuse and the first episode occurred at an early age with greater severity. Teen females that reported a history of past sexual abuse were more likely to report wanting to become pregnant, having a partner that wanted them to become pregnant, and being fearful of infertility because of past abuse than those with no sexual abuse history (Haley et al., 2004). As several studies have reported, there appears to be a pathway from childhood maltreatment to subsequent sexual victimization and risky sexual practices that increases chances of pregnancy among homeless youth.

Mental Health . The focus of a great deal of research on homeless youth has been on the multitude and magnitude of their mental health challenges, including depression (Kennedy, 1991; Unger et al., 1998), anxiety (Kidd, 2004), suicide (Mallett, Rosenthal, Myers, Milburn, & Rotheram-Borus, 2004; Yoder, 1999), and trauma-related disorders (Thompson, 2005; Whitbeck & Simons, 1990). Homeless youth experience higher rates of mental health conditions than young adults in the general population. Estimates of serious psychiatric disorders among homeless youth range from rates of 19–50 % (Robertson & Toro, 1998) and an estimated 20–40 % of homeless youth report having attempted suicide (Kidd, 2004). As they are continually exposed to traumatizing events, their ability to recover and overcome symptoms is impeded (Foy, Eriksson, & Trice, 2001). Youth who fail to seek treatment or remove themselves from dangerous street life are at risk for developing Post-Traumatic Stress Disorder (PTSD ) (McCarthy & Thompson, 2010), with rates of PTSD as high as 30 % (Bender et al., 2013).

Mental health challenges (and comorbid mental health substance use) have been associated with pregnancy among homeless youth (Tyler, Hagewen, & Melander, 2011). As youth become embedded in the culture of homelessness, they are marginalized from society due to lack of housing, difficulty attending to personal hygiene, food insecurity, and societal stigma (Dachner & Tarasuk, 2002; Gaetz & O’Grady, 2002). Their ability to cope with the stress of living on the streets may be inhibited by their experiences of victimization. Thus, the physical and psychological stress associated with pregnancy and the subsequent challenges of caring for a child while homeless only complicates the process by which young women address their mental health challenges and remove themselves from homelessness (Webb, Culhane, Metraux, Robbins, & Culhane, 2003).

Pro-social Disengagement . Homeless youth who disengage from traditional pro-social sources of support through dropping out of school, engaging in delinquent behavior, or becoming entrenched in significant poverty, are at increased risk of pregnancy. Delinquent and criminal behavior has been associated with pregnancy among runaway/homeless females; one study (Thompson, Bender, Lewis, & Watkins, 2008) demonstrated that a significantly greater percentage of runaway females who were or had been pregnant reported being on probation, or charged with a misdemeanor or felony than did their nonpregnant counterparts. Youth who spend longer periods of time without adult supervision and in the company of deviant peers are significantly more likely to engage in delinquent behavior (Heinze, Toro, & Urberg, 2004; Warr, 2002); it is likely that these behaviors co-occur with the runaway/homeless female’s pregnancy.

Disengaging from school, an institution associated with pro-social values and financial independence, places homeless youth at risk for pregnancy. In one national study of runaway youth (Thompson et al., 2008), youth who dropped out of school were more than twice as likely to report being pregnant. Thus, youth who have limited housing stability experience greater educational problems and decreased engagement in their education. Their limited exposure to positive experiences in educational settings—combined with housing instability—may be one factor in becoming pregnant (Thompson, Zittel-Palamara, & Maccio, 2004). Absence from school may decrease development of positive peer relationships and increase peer pressure from similarly situated peers who engage in deviant, high-risk activities such as risky sexual behaviors that lead to sexually transmitted diseases and pregnancy (Tyler, Whitbeck, Hoyt, & Yoder, 2000). Teen pregnancy may exacerbate school problems by creating even greater obstacles to engaging in traditional forms of education (Maynard, 1996), including successfully graduating.

Resource scarcity and impoverished living conditions have also been noted as risk factors for homeless youth pregnancy and early parenthood. Severe financial poverty is nearly synonymous with homelessness and homeless youth are at even greater vulnerability due to the lack of education and employment opportunities. As homeless youth forego educational opportunities due to poor academic performance and school attendance, the result is low educational levels. Coupled with limited work experience and even criminal histories, their success in obtaining and maintaining competitive employment is highly constrained (Whitbeck, 2009). In a recent study (Ferguson, Bender, Thompson, Maccio, & Pollio, 2012), 31 % reported earning their income exclusively from survival behaviors (i.e., prostitution, selling blood/plasma, dealing drugs, stealing, and panhandling) without participating in formal employment. Drug abuse often leads to illegal means of support, including theft, property crimes, drug distribution (Farabee, Shen, Hser, Grella, & Anglin, 2001) and prostitution or survival sex, pimping, pornography, panhandling or conning others (Gaetz & O’Grady, 2002; Greene et al., 1999). All of these activities further combine to suggest higher risk of sexual activity and possible pregnancy.

Pregnancy Motivation . While the vast majority (73 %) of homeless youth pregnancies are unintended (Gelberg et al., 2001), studies suggest that some homeless youth intentionally become pregnant. In a large representative survey of homeless youth, 21 % of the respondents agreed that they would like to become pregnant within the next year and an additional 25 % of youth reported indifference regarding the possibility of pregnancy within the next year (Winetrobe et al., 2013). For some young homeless women, pregnancy was viewed as a positive event and became a reason for them to discontinue their risky lifestyle and assert control over the various decisions associated with exiting homelessness (Saewyc, 2003).

Pregnancy is associated with being homelessness for extended periods of time (Halcón & Lifson, 2004; Milburn, Rotheram-Borus, Rice, Mallet, & Rosenthal, 2006; Slesnick et al., 2006; Thompson et al., 2008; Tucker et al., 2012). Milburn, Rotheram-Borus, et al. (2006) found that 40 % of female youth who had been homeless for 6 months or more had been pregnant one or more times, whereas 14 % of newly homeless female youth reported a lifetime history of pregnancy. In addition, youth who have been homeless longer are significantly more likely to show pro-pregnancy attitudes (Tucker et al., 2012).

Personal, social, and financial benefits may influence reproductive choices. Some may believe that pregnancy and parenthood are solutions to obstacles they face. For example, youth may perceive pregnancy as a conduit toward accessing health care and other social services that they cannot access as a single individual; others may feel pressured by partners to demonstrate the strength of their relationship through parenting (Haley et al., 2004; Smid, Bourgois, & Auerswald, 2010; Tucker et al., 2012).

Several qualitative studies suggest that homeless female youth reported the desire to find love in their lives and becoming pregnant was a way of ensuring unconditional love (Hanna, 2001). Pregnancy and parenting have been described as motivating factors for life changes that create bonds in lieu of relationship voids and feelings of abandonment that homeless youth have often experienced in their families of origin (Thompson et al., 2008; Tucker et al., 2012; Winetrobe et al., 2013). Pro-pregnancy sentiments are also reflected as a way by which a new family unit may be created, existing romantic relationships improved, and an opportunity to display positive parenting skills (Dworsky & Courtney, 2010; Constantine, Jerman, & Constantine, 2009).

Family Risk Factors . Family factors such as lack of intra-familial support, conflict, sexual and physical abuse, and single-parent families have been suggested as risk factors for teen pregnancy (Franklin, Corcoran, & Harris, 2004; Sheaff & Talashek, 1995; Talashek, Alba, & Patel, 2006). Family discord is noted by the majority of runaway/homeless youth as the primary reason for running away (Hyde, 2005; Tyler et al., 2001; Whitbeck, 1999), citing several sources of conflict with their parents or guardians including parental substance use, conflicting religious beliefs, sexual orientation (Cochran, Stewart, Ginzler, & Cauce, 2002), school performance, and personal style such as dress, hair color, or piercing (Hyde, 2005), and disagreements between parents and youth regarding peer groups and choice in romantic partners (Bao et al., 2000). Saewyc (2003) and others have also documented that becoming pregnant is one of the primary reason girls leave or are kicked out of their homes.

Runaway/homeless youth often leave stressful and conflict-ridden home environments (Whitbeck & Simons, 1990; Williams, Lindsey, Kurtz, & Jarvis, 2001; Yoder, Whitbeck, & Hoyt, 2001). Research has shown that at least one-third of homeless youth report a history of trauma exposure from a variety of sources, such as being kicked out of their home, forced into institutional facilities, parents introducing drug use, parental drug use, child welfare placement, parental abandonment/death, imprisonment, family homelessness, parental mental illness, suicide attempts, and rape (Baron & Hartnagel, 1998; Tyler et al., 2001; Whitbeck & Simons, 1990; Yoder et al., 2003). Serious maltreatment is often quite common. One study reported that 80 % of their sample of homeless youth had a parent throw something at them and 43 % had been beaten by a parent (Whitbeck et al., 1997a). These researchers also found high incidence of sexual victimization, as 31 % of females and 11 % of males reported being sexually abused by a parent (Whitbeck et al., 1997a, 1997b).

Serious psychological and behavioral consequences exist for maltreated homeless adolescents. Physically and sexually abused youth run away more often and stay away longer than non-abused homeless youth (Kurtz & Kurtz, 1991). Those who experienced physical and sexual abuse at home are also significantly more likely to meet diagnostic criteria for depression and attempt suicide than youth who have not been abused (Ryan et al., 2000). Homeless youth also experience high rates of intra-familial incest prior to leaving home, which sometimes results in pregnancy (Haley et al., 2004). Conversely, other youth enter homelessness after becoming pregnant and are forced out of their homes by parents or guardians as a result (Meadows-Oliver, 2006).

Pregnancy is associated with generally unstable home environments. In one study of runaway youth across the USA (Thompson et al., 2008), a greater percentage of pregnant teens reported not living with their parent(s) at the time of shelter admission, living in more than two residences during the previous month, and being away from home for longer in comparison to their nonpregnant counterparts. In addition, those from single parent families, who felt abandoned by their parents and who reported emotional abuse by their mothers, were more likely to report being pregnant. This combination of factors suggests these young women had experienced long-term family difficulties and discord, which played a greater role in the disrupted family relationships than occurred among runaway youth who were not pregnant.

These numerous areas of family dysfunction underscore the significance of negative family relationships as predictors of teen pregnancy among runaway youth. Perhaps family relationship problems only escalate when a teen becomes pregnant, making the family environment an unhealthy, unsafe place for the adolescent.

7.5 Consequences of Teen Pregnancy Among Runaway/Homeless Youth

Pregnancy while homeless often results in poorer health and mental health consequences for adolescent mothers, with increased risk for developing acute or chronic health problems (Crawford, Trotter, Hartshorn, & Whitbeck, 2011; Wagner & Menke, 1992). Unfortunately, homeless women are less likely to receive prenatal care and other reproductive health screenings compared to housed women (Seiffge-Krenke et al., 2010). These young women have more medical problems, which increases the likelihood of increased birth complications. Their poor nutritional intake often results in further difficulties during pregnancy as well as providing proper nourishment to their infant. In addition, runaway/homeless youth report high rates of drug and alcohol use while on the streets (Thompson, 2004) and such behaviors tend to continue during pregnancy. One study suggested that 38 % of homeless young women drank alcohol while pregnant (Wagner & Menke, 1992), suggesting high risk of prenatal exposure to substances.

The struggles of homeless mothers have a powerful influence on their children as they often lack health care benefits, access to prenatal care, adequate nutrition, and stable living conditions needed for healthy infants (Meadows-Oliver, 2006; Tischler, Rademeyer, & Vostanis, 2007). Children born to homeless adolescents are more likely to be born preterm, at low birth weight, and experience neurological and physical problems resulting from prenatal nutritional deficits (Chapman, Tarter, Kirisci, & Cornelius, 2007; Little et al., 2005; Oliveira & Goldberg, 2002; Stein, Lu, & Gelberg, 2000). Low birth weight and preterm births are more common among babies born to adolescents in general, but are more likely among homeless youth (Stein et al., 2000).

The mental and physical stresses of both pregnancy and raising a child(ren) have been found to make young women’s departures from homelessness more difficult (Webb et al., 2003). For a population that demonstrates higher than average rates of mental health concerns (Cauce et al., 2000), pregnancy and early parenting only heighten the negative consequences to their lives (Pennbridge, Mackenzie, & Swofford, 1991). Adolescent mothers report greater levels of depression and stress following the birth of their child (Hanna, 2001), and they often experience increased stress from the multiple roles required of being a caregiver to an infant, coupled with difficulties in finding housing and food.

For runaway/homeless teen mothers who carry their pregnancies to term, their lack of resources and stable housing make competent parenting nearly impossible. Youth are typically unprepared to economically, physically, and emotionally care for an infant. Most lack the skills and education necessary to obtain and maintain gainful employment and are forced to engage in survival behaviors such as prostitution, dealing drugs, or other criminal behaviors to gain resources needed to care for their child (Greene, Ringwalt, & Iachan, 1997; Warf et al., 2013). In one study of homeless adolescent mothers, they reported a desire for a stable home for their baby, but the success of this goal was transitory (Ruttan et al., 2012). Many homeless young parents are required to relinquish the child to family members or the child welfare system. With family members often no longer involved in the lives of their runaway/homeless daughters, the infant is most often placed in foster care system rather than with relatives. Although some homeless young women are successful in raising children, pregnancy and child-rearing while homeless clearly creates heightened risk for a host of physical and emotional consequences for the adolescent mother as well as her child.

7.6 Prevention and Intervention Services

This collection of interrelated risk factors for pregnancy suggests that youth who disclose one factor should be closely screened for other risky sexual behaviors or contextual factors. Identifying youth at risk for pregnancy is essential to target prevention efforts efficiently among under-resourced service agencies serving homeless youth. Those young women determined at risk should be provided with comprehensive sexual health education to prevent further health problems and to address the motivations associated with becoming a parent. Because young adults have the lowest help-seeking behavior of any age group, it is important that pregnancy services be accessible, medically accurate, and culturally responsive to this unique and vulnerable population. As a parallel example, close to 60 % of homeless youth in a recent California study reported receiving some form of mental health services, but less than half found them helpful (Bernstein & Foster, 2008). The consequences of not offering appropriate and accessible services for these youth are enormous. Many state policymakers recognize these consequences and express genuine interest in addressing issues for vulnerable populations, but the complex nature of the problem often seems insurmountable. Thus, more research and coordination are needed to inform policymakers concerning how they specifically can assist homeless youth transition out of homelessness into productive, healthy adulthood. As part of these efforts, more effective and appealing methods are needed to encourage homeless youth to become more actively engaged in reclaiming and improving their sexual health and well-being through pregnancy reduction, acquiring accurate sexual and reproductive health knowledge, and through fostering healthy relationships and behaviors.

Recent policy efforts have begun to focus on implementing and evaluating innovative, evidence-based strategies for reducing pregnancies among vulnerable populations, including homeless youth. For example, as part of the Patient Protection and Affordable Care Act (2010), the Personal Responsibility Education Program (PREP) was designed to fund comprehensive, age-appropriate, medically accurate sex education programs to reduce pregnancies and sexually transmitted infections [STIs ]. A portion of PREP funding is allocated annually to better understand burgeoning efforts that seek to reduce pregnancies specifically among high-risk, vulnerable, and culturally under-represented youth populations (ages 10–20 years), including homeless youth, youth in foster care, youth with HIV/AIDS, pregnant women under the age of 21, and youth residing in areas with high birth rates for young parents. While promising results are beginning to emerge from such policy and intervention efforts, a challenge remains regarding funding. As many subgroups of vulnerable populations are targeted by these interventions, insufficient funding is currently allocated for exhaustively exploring and adapting intervention approaches to meet the unique life challenges faced by specific subpopulations. As such, future research efforts should also explore the utility of existing evidence-based intervention approaches, while advocating for increased funding to further adapt interventions such that they best meet the needs of vulnerable youth populations such as runaway/homeless youth.

7.7 Lailah’s Story

Lailah was 15 years old when the fighting in her home got so violent that she felt like her only option was to leave. Violence was common in her home, and while her mother faced the brunt of her father’s aggression, Lailah was also a frequent target. It became too much to bear, and Lailah went to stay with her Aunt Kay. Kay was nice to Lailah but had several kids of her own. The cousins were already sharing rooms and Lailah seemed to be in the way. After several weeks, Kay told Lailah that she needed to find another place to stay. After asking several friends if she could stay at their houses, Lailah ran out of options and found herself without a place to stay.

Lailah was afraid to stay on the streets. It was cold, dirty, and dangerous. She would try to find a bed at the shelter whenever possible, but sometimes there weren’t beds available. During these times, Lailah would find a corner of the park where she was out of sight to catch a couple hours of sleep. Eventually she met other youth hanging out at the park. She met a guy, Ronnie, who was friendly and seemed to think she was special. He was homeless too, but when he found food, he’d share it with Lailah, and eventually they were in a relationship. Ronnie was friends with several other youth who eventually became a surrogate family for Lailah. This street family looked out for one another. For Lailah, it felt good to belong, and her boyfriend and friends provided her with support and resources. Meanwhile, Lailah became disconnected from most people from home. She stopped attending school. She missed some of her friends from home who seemed to have their lives more “together,” yet she felt like they couldn’t understand her current situation.

Lailah had few resources or ways to make money. She was too young to work and had left behind her ID card that was required to receive any sort of employment or services. When flying signs on the corner one evening, a man pulled up and offered Lailah a place to stay. She soon realized he wanted sexual favors in exchange for a spot on his couch. Lailah began to sometimes engage in survival sex in exchange for food, shelter, or cash when she was really desperate for basic necessities. Drinking alcohol and smoking pot made engaging in survival sex less uncomfortable, and Lailah began to use substances more often. Her use of alcohol and drugs numbed her from some of the feelings of depression and trauma symptoms that had increased since leaving home for the streets.

If someone were to ask, Lailah would have said she didn’t feel one way or another about getting pregnant. She knew being a mom might be hard, but it could also motivate her to find more stability in her life. Things were going well with Ronnie, and she imagined that a baby might bring them together for the long-term. Besides, people might be more willing to help her out if she had a baby. Lailah tried to use condoms when she could, but she didn’t always have them with her, and she couldn’t always afford them or find free ones. She felt like protection was less critical when she was with Ronnie because they were in a relationship, so getting pregnant with him seemed less problematic. It was also hard to remember and negotiate condom use when she was drunk or high and engaging in survival sex.

After several months of feeling exhausted and not well, Lailah went to the drop-in clinic to see a doctor, where she discovered she was 4 months pregnant. Without a regular doctor, Lailah wasn’t able to get consistent prenatal care. She found it difficult to eat well or get enough rest while on the streets. Even though she knew it wasn’t good for herself or her baby, she continued to drink and smoke with her friends. Her baby was born prematurely and was very small.

Even though her street family and Ronnie gave Lailah attention and cared for her while pregnant, Lailah felt surprisingly alone after the baby came. The baby was very fussy and hard to soothe. The stress of raising an infant in these conditions only made Lailah’s depression struggles more difficult. It also made it harder to attend job training and other educational services that might help her exit the streets.

Lailah was lucky to find a spot in a housing program for young moms and their babies. However, she continued to use drugs to deal with her depressive problems, and she could not adhere to the clean campus rules of the housing organization. She was asked to leave. With nowhere else to go, she approached the youth shelter where she was welcomed, but was told that the baby could not stay. Child protective services were called because it was clear that Lailah could not adequately care for her baby. Lailah hopes to find more stable housing and a job so that she can get her baby back from the foster care system. She has several steps she needs to take to be successful. She is motivated to make things better for herself, but she feels overwhelmed by the large challenges that seem to be in front of her.

7.8 Conclusion

Homeless youth, a highly vulnerable population to myriad challenging life circumstances and outcomes, experience pregnancy and early parenthood with notably high prevalence. As noted throughout the chapter, the causes and outcomes associated with homeless youth pregnancy are teeming with complexity, and as such, prevention and intervention strategies are not only urgently needed, but also must be crafted to be culturally responsive to the unique needs, risk factors, and difficult life experiences often faced by this population.