Teenage pregnancy is a significant social issue in the United States, resulting in increased levels of poverty. Most public health family planning efforts have traditionally focused on teaching teens the how-to of contraception, with little focus on teaching the why-to. During my time as a nurse practitioner in a public health department family planning clinic, I developed a method to open discussions with patients about the possibilities of a future that includes delayed childbearing. My experience with this strategy taught me that hope may indeed be the most powerful contraceptive of all.
The teen pregnancy rate is at an historic low in the United States (Martin et al., 2007 ). These numbers reassure those of us who work in family planning that we are doing something right. We like to think that the U.S. public health care system is doing an excellent job dispensing birth control to those who can least afford the emotional and financial responsibilities of parenthood: teenage girls. Sadly though, there is much work yet to be done; each year in the United States, 750,000 teens become pregnant (Guttmacher Institute, 2006).
ONE NURSE PRACTITIONER'S EXPERIENCE
As the nurse practitioner in a busy Birmingham, Alabama public health family planning clinic, I cared for hundreds of teens from low-income households. As anyone who has worked with this population in this setting knows, the challenge with these patients was not necessarily getting them on birth control, but rather keeping them on birth control. Just down the hall, the prenatal clinic's appointment book contained far too many names of my former patients lost to unplanned pregnancy.
Most of my young patients were still in high school and at the age of looking forward to an exciting future. Only . . . they weren't. For so many of these teens, faith in a better tomorrow was simply not part of the landscape. Instead, many of our adolescent patients assumed that their lives would be eternally bound by the cycle of poverty. In our society the road to independence begins with a college degree; however, teen mothers are much less likely to attend college than their childless counterparts (Hofferth, Redi, & Mott, 2001). Conversely, adolescents who complete college, marry in their 20s or later, and delay childbearing until marriage are much more likely to avoid poverty (Zill & O'Donnell, 2004).
Many of us take the future for granted; in fact, this faith in the future is a defining characteristic of being American. For example, membership in my generation and culture came with the assurances that we would graduate from college, get good jobs, and achieve independence. The concept of a future was never in question at the dinner table. Eventually, however, I learned that not everyone has a vision of the future as a birthright.
Jane Fonda's autobiography (2005) recounts the words that Lulu, a 14-yearold African American, spoke when describing the experience of interacting with counselors at Fonda's summer camp for disadvantaged kids: "It's the first time I've been with people who think about the future" (p. 383). Within the same passage, Fonda reminds us of the old saying: "The rich plan for generations; the poor plan for Saturday nights" (p. 384). Successful escape from the poverty cycle is a difficult journey that takes "a sustained effort, skill, practice, discipline, deferred gratification, parental dedication and social support" (Whitehead & Pearson, 2006, p. 18).
HOPE AS CONTRACEPTIVE
While working with adolescent girls, I began to see the critical connections between hope and birth control. I began to believe that our clinic could offer more than oral contraceptives and condoms-We could offer a better future, a leg up in the quest to reach the summit of Maslow's pyramid (Maslow, 1970). But what exactly were our young patients' hopes, dreams, and goals? I became determined to make a "dream assessment" part of every teen visit. …