Durante décadas, los índices de esta infección de transmisión sexual fueron bajos. Pero el Departamento de Salud del condado de Hamilton, en Chattanooga, una ciudad mediana rodeada de bosques nacionales y situada a los pies de los Apalaches de Tennessee, atendía a varios pacientes de sífilis al día, explicó Miller.

Lo que Miller observó en Chattanooga refleja una tendencia que está disparando alarmas en los departamentos de salud de todo el país.

A nivel nacional, las tasas de sífilis . Los Centros para el Control y Prevención de Enfermedades (CDC) que se reportaron 207,255 casos en 2022, lo que continúa un fuerte aumento en cinco años.

Entre 2018 y 2022, las tasas de sífilis subieron alrededor del 80%. La epidemia de infecciones de transmisión sexual, especialmente la sífilis, está “”, dijo la Coalición Nacional de Directores de ETS.

El repunte ha sido aún más pronunciado en Tennessee, donde las tasas de infección por de la sífilis entre 2017 y 2021.

Pero esta situación ya difícil se complicó la primavera pasada por la escasez de una inyección específica de penicilina que es el tratamiento de referencia para la sífilis.

Esta escasez actual es tan grave que las agencias de salud pública han recomendado que los proveedores racionen el medicamento, dando prioridad a las pacientes embarazadas, ya que es el único tratamiento de la sífilis considerado seguro para ellas. La sífilis congénita, que ocurre cuando la madre transmite la enfermedad al feto, puede causar malformaciones congénitas, abortos espontáneos y mortinatos (muerte fetal).

Según datos recientes, en 2022 se notificaron a los CDC 3,755 casos de sífilis congénita en todo el país, que hace una década. De esos casos, 231 dieron lugar a mortinatos y 51 provocaron la muerte del bebé. El número de casos en bebés se ha elevado un 183% entre 2018 y 2022.

“La falta de pruebas oportunas y tratamiento adecuado durante el embarazo contribuyó al 88% de los casos de sífilis congénita”, indicó publicado en noviembre. “Las brechas en las pruebas y el tratamiento estuvieron presentes en la mayoría de los casos en todas las razas, etnias y regiones de la Oficina del Censo de Estados Unidos”.

Las tasas de sífilis del condado de Hamilton han reflejado la tendencia nacional, con un aumento de los casos en todos los grupos, incluidos los lactantes.

En noviembre, la organización de defensa materno infantil March of Dimes publicó su. En el reporte se constata que, en todo el país, alrededor del 15,5% de las embarazadas recibe atención a partir del quinto mes de gestación o más tarde, o acude a menos de la mitad de las visitas prenatales recomendadas. En Tennessee, la tasa era aún peor, del 17,4%.

Pero Miller dijo que incluso quienes van a todas las citas recomendadas pueden tener problemas porque los proveedores están obligados a realizar pruebas de sífilis solo al principio del embarazo. La idea es que si se hace la prueba unas semanas antes del parto, hay tiempo para tratar la infección.

Sin embargo, esa recomendación depende de si el profesional de salud sospecha que la paciente ha estado expuesta a la bacteria que causa la sífilis, lo que puede no ser obvio para las personas que dicen que sus relaciones son monógamas.

“Lo que descubrimos es que, muchas veces, la pareja no es tan monógama y trae la sífilis a la relación”, explicó Miller.

Incluso si la paciente dio negativo inicialmente, puede haber contraído la sífilis más adelante en el embarazo, cuando las pruebas de detección de la enfermedad no son rutinarias, dijo.

Para tratar la sífilis se utilizan dos antibióticos: la penicilina inyectable y un fármaco oral llamado doxiciclina.

A los pacientes alérgicos a la penicilina se les suele recetar el antibiótico oral. Pero la Organización Mundial de la Salud porque puede causar graves deformidades óseas y dentales en el bebé.

Por ello, las pacientes embarazadas con sífilis suelen recibir penicilina, aunque sean alérgicas, mediante una técnica llamada desensibilización, explicó Mark Turrentine, ginecólogo y obstetra de Houston. A las pacientes se les administran dosis bajas en un entorno hospitalario para ayudar a su organismo a acostumbrarse al fármaco y comprobar si se produce una reacción grave. La inyección de penicilina es una técnica de un solo uso, a diferencia de los antibióticos, que requieren un curso de tratamiento de dos semanas.

“Es difícil tomar un medicamento durante un largo período de tiempo”, afirmó Turrentine. La inyección única puede dar tranquilidad a los pacientes y a sus médicos. “Si no vuelven por el motivo que sea, no hay que preocuparse”, dijo.

El Departamento de Salud Pública Metropolitana de Nashville, Tennessee, empezó a administrar el antibiótico oral a todas las adultas no embarazadas con sífilis en julio, según dijo Laura Varnier, directora clínica y de enfermería.

Turrentine dijo que empezó a ver avisos sobre la escasez de penicilina inyectable en abril, más o menos cuando el antibiótico y los médicos empezaron a utilizar la penicilina como sustituto, precipitando potencialmente la escasez, dijo.

El aumento de la sífilis ha creado una demanda de la inyección que el fabricante , según la American Society of Health-System Pharmacists (ASHP). “El suministro es insuficiente para los pedidos habituales”, afirmó la ASHP en una nota.

Aunque la penicilina existe desde hace mucho tiempo, fabricarla es difícil, en gran parte porque mucha gente es alérgica, dijo Erin Fox, jefa asociada de farmacia del sistema de salud de la Universidad de Utah y profesora adjunta de la universidad, que estudia la escasez de medicamentos.

“Eso significa que no se pueden fabricar otros fármacos en esa línea de producción”, explicó. Solo los grandes fabricantes como Pfizer disponen de los recursos necesarios para construir y gestionar instalaciones tan especializadas. “No es necesariamente eficiente ni rentable”, dijo Fox.

En un comunicado, Pfizer confirmó que la escasez de amoxicilina y el aumento de la sífilis incrementaron la demanda de penicilina inyectable en un 70%. Según sus representantes, la empresa invirtió $38 millones en las instalaciones que producen esta forma de penicilina, al contratar más personal y ampliar la línea de producción.

“Este aumento tardará algún tiempo en notarse en el mercado, ya que el ciclo de producción es de 3 a 6 meses desde que se fabrica el producto hasta que está disponible para los consumidores”, según el comunicado. La empresa calcula que la escasez se reducirá considerablemente durante la primavera.

Mientras tanto, dijo Miller, su clínica de Chattanooga continúa elaborando estrategias. Cada dosis de penicilina inyectable puede costar cientos de dólares. Además, hay que conservarla en frío y caduca a los 48 meses.

Incluso con el espectacular aumento de casos, la sífilis sigue siendo relativamente rara. Más de 7 millones de personas viven en Tennessee, y en 2019, los proveedores de todo el estado informaron .

Los departamentos de salud como el de Miller tratan a la mayor parte de los pacientes con sífilis. A la mayoría los envían sus médicos. El departamento trabaja con rastreadores de contactos para identificar y notificar a las parejas sexuales que podrían estar afectadas y realiza pruebas a los pacientes para detectar otras infecciones de transmisión sexual, incluido el VIH.

“Cuando diagnosticas en el consultorio, piensa que solo estás viendo la punta del iceberg”, afirmó Miller. “Necesitas un equipo de individuos para poder explorar y ver el resto del iceberg”.

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For decades, rates of the sexually transmitted infection were low. But the Hamilton County Health Department in Chattanooga — a midsize city surrounded by national forests and nestled into the Appalachian foothills of Tennessee — was seeing several syphilis patients a day, Miller said. A nurse who had worked at the clinic for decades told Miller the wave of patients was a radical change from the norm.

What Miller observed in Chattanooga is reflective of a trend that is raising alarm bells for health departments across the country.

Nationwide, syphilis rates . The Centers for Disease Control and Prevention that 207,255 cases were reported in 2022, continuing a steep increase over five years. Between 2018 and 2022, syphilis rates rose about 80%. The epidemic of sexually transmitted infections — especially syphilis — is “,” said the National Coalition of STD Directors.

The surge has been even more pronounced in Tennessee, where infection rates for the of syphilis between 2017 and 2021.

But this already difficult situation was complicated last spring by a shortage of a specific penicillin injection that is the go-to treatment for syphilis. The ongoing shortage is so severe that public health agencies have recommended that providers ration the drug — prioritizing pregnant patients, since it is the only syphilis treatment considered safe for them. Congenital syphilis, which happens when the mom spreads the disease to the fetus, can cause birth defects, miscarriages, and stillbirths.

Across the country, 3,755 cases of congenital syphilis were reported to the CDC in 2022 — that’s as the number a decade before, the recent data shows. Of those cases, 231 resulted in stillbirth and 51 led to infant death. The number of cases in babies swelled by 183% between 2018 and 2022.

“Lack of timely testing and adequate treatment during pregnancy contributed to 88% of cases of congenital syphilis,” said a released in November. “Testing and treatment gaps were present in the majority of cases across all races, ethnicities, and U.S. Census Bureau regions.”

Hamilton County’s syphilis rates have mirrored the national trend, with an increase in cases for all groups, including infants.

In November, the maternal and infant health advocacy organization March of Dimes released its annual . It found that, nationwide, about 15.5% of pregnant people received care beginning in the fifth month of pregnancy or later — or attended fewer than half the recommended prenatal visits. In Tennessee, the rate was even worse, 17.4%.

But Miller said even those who attend every recommended appointment can run into problems because providers are required to test for syphilis only at the beginning of a pregnancy. The idea is that if you test a few weeks before birth, there is time to treat the infection.

However, that recommendation hinges on whether the provider suspects the patient was exposed to the bacterium that causes syphilis, which may not be obvious for people who say their relationships are monogamous.

“What we found is, a lot of times their partner was not as monogamous, and they were bringing it into the relationship,” Miller said.

Even if the patient tested negative initially, they may have contracted syphilis later in pregnancy, when testing for the disease is not routine, he said.

Two antibiotics are used to treat syphilis, the injectable penicillin and an oral drug called doxycycline.

Patients allergic to penicillin are often prescribed the oral antibiotic. But the World Health Organization strongly because it can cause severe bone and teeth deformities in the infant.

As a result, pregnant syphilis patients are often given penicillin, even when they’re allergic, using a technique called desensitization, said Mark Turrentine, a Houston OB-GYN. Patients are given low doses in a hospital setting to help their bodies get used to the drug and to check for a severe reaction. The penicillin shot is a one-and-done technique, unlike an antibiotic, which requires sticking to a two-week regimen.

“It’s tough to take a medication for a long period of time,” Turrentine said. The single injection can provide patients and their clinicians peace of mind. “If they don’t come back for whatever reason, you’re not worried about it,” he said.

The Metro Public Health Department in Nashville, Tennessee, began giving all nonpregnant adults with syphilis the oral antibiotic in July, said Laura Varnier, nursing and clinical director.

Turrentine said he started seeing advisories about the injectable penicillin shortage in April, around the time the antibiotic and physicians were using penicillin as a substitute, potentially precipitating the shortage, he said.

The rise in syphilis has created demand for the injection that manufacturer with, according to the American Society of Health-System Pharmacists. “There is insufficient supply for usual ordering,” the ASHP said in a memo.

Even though penicillin has been around a long time, manufacturing it is difficult, largely because so many people are allergic, said Erin Fox, associate chief pharmacy officer for the University of Utah health system and an adjunct professor at the university, who studies drug shortages.

“That means you can’t make other drugs on that manufacturing line,” she said. Only major manufacturers like Pfizer have the resources to build and operate such a specialized, cordoned-off facility. “It’s not necessarily efficient — or necessarily profitable,” Fox said.

In a statement, Pfizer confirmed the amoxicillin shortage and surge in syphilis increased demand for injectable penicillin by about 70%. Representatives said the company invested $38 million in the facility that produces this form of penicillin, hiring more staff and expanding the production line.

“This ramp up will take some time to be felt in the market, as product cycle time is 3-6 months from when product is manufactured to when it is available to be released to customers,” the statement reads. The company estimated the shortage would be significantly alleviated by spring.

In the meantime, Miller said, his clinic in Chattanooga is continuing to strategize. Each dose of injectable penicillin can cost hundreds of dollars. Plus, it has to be placed in cold storage, and it expires after 48 months.

Even with the dramatic increase in cases, syphilis is still relatively rare. More than 7 million people live in Tennessee, and in 2019, providers statewide .

Health departments like Miller’s treat the bulk of syphilis patients. Many patients are sent by their provider to the health department, which works with contact tracers to identify and notify sexual partners who might be affected and tests patients for other sexually transmitted infections, including HIV.

“When you diagnose in the office, think of it as just seeing the tip of the iceberg,” Miller said. “You need a team of individuals to be able to explore and look at the rest of the iceberg.”

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Sólo del país empiezan la jornada antes de las 7:30 de la mañana, según estadísticas federales. Pero en Nashville, las clases empiezan a las 7:05, algo que su nuevo alcalde, Freddie O’Connell, lleva años criticando.

“No es algo de lo que enorgullecerse”, se lamentó en una ocasión, cuando aún era concejal.

Desde su elección en septiembre, O’Connell tiene como principal meta de su agenda educativa retrasar la hora del comienzo de clases. Tanto él como otras voces en todo el país llevan insistiendo en que no es que los adolescentes sean vagos o quieran dormir más. Es una cuestión de ciencia.

“Todos los adolescentes registran un cambio en el cerebro que les hace no tener sueño hasta las 10:45 u 11 de la noche”, explicó , investigadora de la Facultad de Educación y Desarrollo Humano de la Universidad de Minnesota. Wahlstrom, quien fue maestra, estudia las consecuencias de las políticas de educación en el aprendizaje. “Es un cambio que decide la biología”.

La falta de sueño en adolescentes se vincula a problemas de salud mental, peores calificaciones, accidentes de tránsito y mucho más. Por eso, estados como California y Florida han ordenado retrasar la hora de inicio de las clases. Algunos distritos de todo el país —incluidos algunos de Tennessee— han hecho el mismo cambio.

Pero la resistencia a empezar más tarde tiene menos que ver con dificultades logísticas y financieras, sobre todo en aspectos básicos como el transporte escolar.

El representante estatal , demócrata de Nashville, intentó aprobar en 2022 un que obligaba a retrasar el horario de inicio de clase.

“Estoy empezando a comprobarlo con uno de mis hijos”, dijo durante una audiencia a nivel de comité de su proyecto de ley. Clemmons profundizó en el aspecto biológico, incluida la melatonina, la famosa hormona del sueño.

La melatonina produce somnolencia. El cerebro empieza a producirla cuando oscurece y alcanza su máximo a mitad de la noche. El cerebro de los adolescentes empieza a liberar melatonina más tarde que el de los adultos y el de niños, según la Sociedad Americana de Química. Así que cuando los adolescentes se despiertan temprano, su cerebro aún sigue produciendo melatonina.

“Debido a la forma en que los cuerpos de los adolescentes liberan melatonina, despertar a un adolescente a las 7 de la mañana es similar a despertar a uno de nosotros a las 4 de la mañana”, explicó Clemmons.

El legislador aportó el testimonio de una madre local, Anna Thorsen, quien declaró que una legislación que retrasara el horario de inicio podría proteger a niños vulnerables como el suyo.

“Mi hija menor es estudiante de noveno grado y sufre una rara epilepsia genética que mató a su hermana mayor el año pasado”, dijo. “De hecho, en marzo pasado, mi hija menor tuvo una convulsión potencialmente mortal que fue parcialmente inducida por la falta de sueño”.

El representante , republicano del área de Knoxville, indicó que casi todos los comentarios que escuchó sobre el proyecto de ley provenían de Nashville.

“Ve a tu consejo escolar y diles que cambien la norma, que cambien la ley, que cambien su horario de inicio”, dijo. “Pero, ¿obligar [al resto del estado] a hacerlo por culpa de un consejo escolar que no quiere escuchar a sus padres?”.

Los líderes legislativos escucharon sobre el proyecto en una audiencia, pero no se convirtió en ley.

Ante esta situación, Nashville, una ciudad que a menudo se autodenomina el Silicon Valley de la industria de salud, tendrá que buscar su propio camino. Y O’Connell ha puesto manos a la obra.

El alcalde tiene cierto poder sobre el presupuesto escolar, lo que le permite influenciar la política educativa. Pero es al Consejo Escolar al que le corresponde decidir los horarios.

“Un horario con un inicio temprano, sobre todo para los adolescentes, es problemático”, dijo el alcalde. “También sabemos que hacer un cambio —incluso de 30 minutos— requiere de muchos ajustes logísticos”.

Una de las principales preocupaciones ha sido el transporte escolar. Incluso en épocas normales, los distritos utilizan los mismos autobuses y conductores para alumnos de todas las edades. Para ello escalonan los horarios, de tal manera que los alumnos de secundaria sean los primeros en entrar y salir.

La razón es que al ser mayores, pueden estar solos en la oscuridad en una parada de autobús más fácilmente que los niños más pequeños, y también les permite llegar a casa primero para ayudar a cuidar de sus hermanos menores después de la escuela.

Si las secundarias empezaran a la misma hora que las escuelas intermedias y las primarias, eso probablemente aumentaría la presión sobre el transporte. O’Connell dijo que el hecho de que el transporte público sea limitado en Nashville agrava el problema.

“Es uno de los mayores problemas que hay que resolver”, señaló.

Hace varios años, Collierville, un distrito de los suburbios de Memphis, puso en marcha un estudio sobre el horario de inicio de las clases. Este distrito tiene muchos menos alumnos: 9,000, frente a de Nashville.

Los funcionarios de Collierville estimaron en el estudio que los costos de transporte en autobús asociados con el retraso de la hora de inicio de clases podrían ascender a $1.4 millones anuales. En esos cálculos se contaba que el distrito necesitaría más conductores, más combustible y mantenimiento, más almacenes y personal de apoyo, como despachadores y mecánicos.

A pesar de ello, el distrito retrasó la hora de inicio de la escuela secundaria en 2018.

O’Connell dijo que una de las preocupaciones que ha escuchado de los padres es financiera, en el sentido de que necesitan que una vez que sus hijos acaban la jornada escolar, les ayuden en sus negocios familiares o generando ingresos para la familia yendo a trabajar.

La sleep Foundation, una organización sin fines de lucro que aboga por retrasar la hora del inicio de clases, realizó una encuesta en 2022 entre padres, profesores y otros adultos, que halló que solo un tercio de los padres que respondieron querían que se retrasara el horario. Los adultos en su conjunto y los profesores respondieron de forma ligeramente más favorable, pero menos del 40% de cada grupo apoyaba retrasar la jornada.

Un de la National education Association de 2022 concluyó que muchos padres que se oponen a retrasar la hora de entrada a la escuela no lo hacen por necesariamente tener dudas sobre las razones científicas detrás de la medida, sino que les preocupa cómo afectará a la planificación diaria de su familia.

Wahlstrom, la investigadora en educación, teme que los padres subestimen la importancia del sueño en el desarrollo del cerebro y el rendimiento académico.

“A veces, tanto los padres como los adolescentes piensan que pueden recuperar el sueño durante el fin de semana. Es una suposición totalmente falsa”, resaltó Wahlstrom, quien comparó el dormir con alimentar el cerebro. “Es como decir: ‘Ok, vamos a privarnos de una alimentación adecuada tres días a la semana, pero luego vamos a atiborrarnos de comida el fin de semana’. Eso no es sano”.

Asimismo, explicó que la falta de sueño puede impedir el éxito escolar: el cerebro almacena la memoria a largo plazo durante el sueño profundo, por lo que perder ese descanso significa retener menos material.

Pero lo más importante es que el sueño ayuda a los adolescentes a mejorar su salud mental. El Cirujano General de EE.UU., Vivek Murthy, ha dado la voz de alarma acerca del estado de la salud mental de los jóvenes, al señalar que un tercio de los adolescentes en general y la mitad de las adolescentes han manifestado tener sentimientos persistentes de desánimo.

Y Wahlstrom dijo que la privación de sueño en la adolescencia conduce a una peor salud mental y un peor comportamiento, lo que puede afectar a toda la familia.

Con su equipo llevaron a cabo un estudio financiado por los Centros para el Control y Prevención de Enfermedades (CDC) sobre los efectos de retrasar la hora de inicio en estudiantes de noveno a duodécimo grado. Entre 2010 y 2013, realizaron una encuesta a 9,000 estudiantes en ocho escuelas secundarias en Minnesota, Colorado y Wyoming en la que descubrieron que los estudiantes que dormían al menos ocho horas, eran menos propensos a reportar síntomas de depresión.

“Sabemos que hay un mayor consumo de drogas, cigarrillos y alcohol cuando un adolescente duerme menos de ocho horas”, indicó. “También sabemos que existe una relación significativa entre la depresión adolescente y un período de sueño inferior a ocho horas”.

Más del en un distrito escolar de Minnesota, como parte de un estudio anterior de la investigadora, respondieron que se hizo más fácil la convivencia con su hijo adolescente una vez entró en vigencia el retraso en el comienzo de clases.

“Muchos padres me han dicho de forma anecdótica que su hijo es diferente. Pueden hablar con ellos en el desayuno. Hablan más en el auto. No tienen episodios de mal humor”, explicó. “Los padres dicen que es extraordinario que esto les haya cambiado tanto la vida a sus hijos y a la dinámica familiar”.

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Just 10% of public schools nationwide , according to federal statistics. But in Nashville, classes start at 7:05 — a fact the new mayor, Freddie O’Connell, has been criticizing for years.

“It’s not a badge of honor,” he said when he was still a city council member.

Since his election in September, O’Connell has announced that pushing back school start times is a cornerstone of the education policy he is promoting. He and others around the country have been trying to stress that teenagers aren’t lazy or to blame for getting too little sleep. It’s science.

“All teenagers have this shift in their brain that causes them to not feel sleepy until about 10:45 or 11 at night,” said , a senior research fellow at the University of Minnesota in the College of Education and Human Development. She studies how education policy affects learning, and she used to be a teacher. “It’s a shift that is biologically determined.”

Sleep deprivation in teenagers is linked to mental health struggles, worse grades, traffic accidents, and more. That’s why states including California and Florida have mandated later start times. Individual districts across the country — including some in Tennessee — have made the same change.

But resistance to later starts is less about the science than it is about logistical and financial difficulties, especially with basics like busing.

State Rep. , a Nashville Democrat, tried to pass in 2022.

“I’m starting to experience this with one of my own children,” he said during a committee hearing on the bill. He dug into the biology, including the famous sleep hormone melatonin.

Melatonin makes people feel drowsy. The brain starts producing it when it gets dark outside, and its production peaks in the middle of the night. Adolescents’ brains start releasing melatonin about than adults’ and younger children’s brains, according to the American Chemical Society. When teens wake up early, their brains are still producing melatonin.

“Because of the way adolescents’ bodies release melatonin, waking a teen at 7 a.m. is akin to waking one of us at 4 a.m.,” Clemmons said.

He brought in a local parent, Anna Thorsen, who testified that later start time legislation could protect vulnerable kids like hers.

“My youngest daughter is a freshman who suffers from a rare genetic epilepsy that killed her older sister last year,” she said. “In fact, last March, my youngest daughter had a life-threatening seizure that was partially induced by sleep deprivation.”

, a Knoxville-area Republican, said almost all the feedback he heard on the bill came from Nashville.

“Go to your school board and tell them to change the rule, change the law, change their start times,” he said. “But to mandate [the rest of the state] do this because of one school board that doesn’t want to listen to their parents?”

Legislative leaders gave the bill one hearing. It didn’t pass into state law.

That leaves Nashville, a city that often calls itself the Silicon Valley of health care, to figure out its own path. O’Connell is now on the case. The mayor has some power over the school budget, which gives him influence in education policy. However, it’s up to the school board to determine start times.

“Early start times, particularly for adolescents, are problematic,” the mayor said. “We also know that making a change — even a 30-minute change — has a lot of logistics.”

A major concern has been busing. Even in normal times, districts use the same buses and drivers for students of all ages. They stagger start times to do that, with high schoolers arriving and leaving school earliest in the day. The idea is that they can handle being alone in the dark at a bus stop more readily than smaller children, and it also lets them get home first to help take care of younger siblings after school.

If high schools started as late as middle and elementary schools, that would likely mean strain on transportation resources. O’Connell said Nashville’s limited mass transit compounds the problem.

“That is one of the biggest issues to resolve,” he said.

Several years ago, Collierville, a district in suburban Memphis, launched a study on school start times. That district serves far fewer students — 9,000, compared with .

Collierville officials estimated in the study that busing costs associated with delayed start times could be as high as $1.4 million annually. That estimate assumed the district would need more drivers, more fuel and maintenance, more storage facilities, and additional support personnel — for example, an additional dispatcher and mechanic.

Despite that, the district did push back high school start times in 2018.

O’Connell said one of the concerns he has heard from parents is financial, such as that they need help with family-run businesses or they need their students to help generate household income at other jobs after school lets out.

The , a nonprofit that advocates for later start times, conducted a 2022 survey of parents, teachers, and other adults that found that only about one-third of the parents who responded wanted later starts. Adults as a whole and teachers responded slightly more favorably, but less than 40% of each group supported delaying the day.

A National Education Association found that many parents who oppose later start times don’t necessarily doubt the science; they’re concerned about scheduling.

Wahlstrom, the education researcher, said she fears parents underestimate how important sleep is to brain development and academic performance, especially on weeknights.

“Sometimes both parents and teens think that they can just catch up on their sleep on the weekend. That is a total false assumption,” said Wahlstrom, who equated sleep to food for the brain. “It’s like, ‘OK, we’re going to deprive ourselves of adequate food three days out of the week, but then we’re going to gorge on food on the weekend.’ That’s not healthy.”

She explained how a lack of sleep can impede scholastic success: The brain shifts memory into long-term storage during deep sleep, so missing out on that rest means retaining less material.

But — perhaps more importantly — sleep helps teenagers improve their mental health. U.S. Surgeon General Vivek Murthy has been raising alarm bells about youth mental health, noting that a third of teenagers overall and half of teenage girls have reported persistent feelings of hopelessness.

And Wahlstrom said teen sleep deprivation leads to worse mental and behavioral health, which can affect the whole family. She and her team conducted a study funded by the Centers for Disease Control and Prevention on the effects of later start times on ninth to 12th graders by surveying 9,000 students at eight high schools in Minnesota, Colorado, and Wyoming from 2010 to 2013. They found students who got at least eight hours of sleep were less likely to report symptoms of depression.

“We do know that there is greater use of drugs, cigarettes, and alcohol when a teen is getting less than eight hours,” she said. “We also know that there is a significant link between teenage depression and any sleep amount that is less than eight hours.”

More than surveyed in a Minnesota school district as part of one of her earlier studies responded that their teenager was easier to live with after the later start time went into effect.

“Many parents have anecdotally told me that their child is a different child. They are able to speak with them at breakfast. They are chatty in the car. They don’t have moody episodes and fly off the handle,” she said. “The parents are just saying it’s remarkable that this has made such a change in their child’s life and their family dynamics.”

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Wilson founded a nonprofit called Sunnyside Up Youth Pregnancy Services, which connects girls ages 13 to 19 with resources they need to care for their babies. After-hours, she looks for affordable Nashville apartments, books medical appointments, tries to find strollers and other baby supplies, and hosts conversations with pregnant teens about breastfeeding and preparing mentally for childbirth.

Since the overturning of Roe v. Wade just over a year ago, Wilson said, she is confident that more Tennessee teens will carry their pregnancies to term. “Because the access isn’t there,” she said. “I do anticipate that we’re going to get a lot more teens that are wanting to parent their babies rather than going to Illinois or Georgia or Florida.”

Demand for services like Wilson’s could rise in the coming years even though the national teen birth rate has declined dramatically over the past three decades. It’s still dropping, but preliminary data released in June by the Centers for Disease Control and Prevention shows the descent may be slowing.

Doctors, service providers, and advocates say they’re worried full CDC data released later this year — which will include state-by-state numbers — could show a rise in teen births in many , where rates remain among the highest in the country. They say several factors — including the to strike down federal protections for abortion rights, intensifying political pushback against sex education, and on youth mental health — could start to unravel decades of progress.

“It’s absolutely concerning,” said Laura Andreson, an OB-GYN in Franklin, Tennessee. The women’s health practice where she works is treating more pregnant teenagers than in recent years, which she thinks could reflect an emerging trend.

“It’s probably going to take a little bit of time,” she said. “But I would venture to say we’re going to see it every year: It’s going to go up.”

Nationally, the rate of teen births has dropped by 78% since a modern-day peak in 1991 of 61.8 births per 100,000 people, according to the CDC. Starting in 2007, the rate had consistently dropped by about 8% until 2021, when the rate of decline slowed to about 2%.

“It certainly does stand in contrast to what we’ve seen in prior years,” said CDC researcher Brady Hamilton. He is working on the updated version of the national data released in June that will break it down by state. Hamilton said that he can’t comment on the recent social and political factors at play, but that the “phenomenal decline” in the teen birth rates over more than 15 years could be reaching a natural plateau as states achieved their goals.

“There are a lot of states that have very low birth rates,” he said. “So you kind of potentially run into a situation where they’re already low and you really can’t go lower.”

But advocates say this leveling off could be the writing on the wall, signaling the start of a rise in teen births.

“We know that young people came back from the pandemic with record levels of mental health struggles, which can be very tied to things like teen pregnancy,” said Jen Biundo, senior director of research and policy at Healthy Futures of Texas, a nonprofit that advocates for science-based education to curb teen pregnancy. A person with mental health issues may be more likely to form unhealthy relationships and engage in riskier sexual behaviors, she said.

And the unleashed a sea change of legislation across the nation affecting reproductive health and options for women. States like Tennessee enacted so-called trigger laws, overturning the right to most abortions. In August, an all-male South Carolina Supreme Court upheld what abortion opponents sometimes call a “,” which bans most abortions after about six weeks of pregnancy. The term is a misnomer because a fetus’ heart is not fully developed in the early stages of pregnancy.

The sudden shift in the reproductive health landscape concerns Hannah Lantos, a researcher who specializes in maternal and adolescent health for Child Trends, a nonprofit research center. She said changes in abortion policy likely won’t have major effects on teen birth statistics because most abortion patients aren’t teenagers. Teenagers account for only 9% of abortions and 6% of all pregnancies reported in the U.S. each year, according to a . Yet who do get pregnant in the U.S. will opt for an abortion, according to the Department of Health and Human Services.

Previous declines in the teen birth rate weren’t driven by access to abortions alone, Lantos said. Other factors like increased access to and more effective contraceptive methods and sex education contributed. Now, those tools also are under siege in many states.

In Texas, some school boards have amid backlash from parents. In New Hampshire, Republican state officials in federal sex ed funding, and officials in Miami-Dade County, Florida, banned new sex ed books. In Idaho, lawmakers told the state’s health departments the state would no longer fund adolescent pregnancy prevention programs.

Parents who oppose abortion could prevent their children from getting one. Even if the parents acquiesce, incentive for a teen is low, said Wilson of Sunnyside Up. People might need to for abortion care now. That’s particularly tricky for teenagers, who may be too young to make decisions independently.

“That car ride can be very excruciating,” Wilson said, noting that the drive from Nashville to the nearest abortion clinic — in Carbondale, Illinois — can take seven hours. “That’s seven hours of potential silence. That’s seven hours of tension. That’s seven hours of thinking about what’s next. And that is a long time to process something so difficult.”

The fear of a disapproving parent might also prevent a teenager who decides to keep the baby from revealing the pregnancy early on, Andreson said. That could lead to a lack of prenatal care, which is concerning for teens, given they are more likely to have complications than other expectant mothers.

“Their bodies aren’t designed to have babies yet,” she said. “And this doesn’t even go into all the issues that go on once the baby’s born.”

Wilson, from Sunnyside Up, noted that teenage parents face unique challenges taking care of newborns. “It’s a lot for them,” Wilson said of the teens who seek her help. “They need that hands-on, in-person support.”

And one of the greatest challenges is housing. Teenagers need a co-signer on a lease. Even when they find a place, the median rent in Nashville , and Tennessee observes the federal minimum wage of $7.25 an hour. Sunnyside Up has persuaded clients to become roommates.

“It’s like we’re literally having to stack families together in the same household for them to be able to pay basic living expenses,” Wilson said.

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