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11McLaughlin SD: Do Adolescents Who Relinquish Their Children Fare Better or Worse Than Those Who Raise Them?
13Unger J, Molina G, Teran L: Perceived consequences of teenage childbearing among adolescent girls in an urban sample. 14Farrow A, Hull MG, Northstone K et al: Prolonged use of oral contraception before a planned pregnancy is associated with a decreased risk of delayed conception. 16Stevens-Simon C, Kelly L, Singer D et al: Why pregnant adolescents say they did not use contraceptives prior to conception. 17Hellerstedt W, Fee R, McNeely C et al: Pregnancy feelings among adolescents awaiting pregnancy test results. 18Crosby R, Di CR, Wingood G et al: Low parental monitoring predicts subsequent pregnancy among African-American adolescent females.
21Stouthamer-Loeber M, Wei EH: The precoursors of young fatherhood and its effect on delinquency of teenage males. 22Resnick MD, Chambliss SA, Blum RW: Health and risk behaviors of urban males involved in a pregnancy. 23Anda RF, Felitti VJ, Chapman DP et al: Abused boys, battered mothers, and male involvement in teen pregnancy. 24Taylor DJ, Chavez GF, Adams EJ et al: Demographic characteristics in adult paternity for first births to adolescents under 15 years of age. 28Lara-Torre E, Schroeder B: Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills. The result is a teenage pregnancy rate that is twice as high as rates in Canada, England, or France and seven times as high as the teenage pregnancy rate in the Netherlands.4Although the percentage of young adolescents (younger than age 15) having intercourse is smaller than the percent of older adolescents having sex, the medical risks related to a subsequent pregnancy are greater for younger teens.
Young adolescents who are sexually active are more likely to have been abused, more likely to report multiple sex partners, and face greater obstetrical risks during pregnancy. The negative medical and social consequences of adolescent pregnancy are considerable, and programs to reduce the incidence and ramifications of adolescent pregnancy must be multidimensional in their approach to adolescent pregnancy prevention. Thirty five percent of teenagers 15–19 years old had elective abortions, with 65% of them continuing their pregnancy.
The following graphs show a steady decline in the pregnancy rate, birth rate, and abortion rate from an all time high in 1991 to a low noted in 2005.
Based on these assumptions, prevention programs focused efforts toward provision of contraception, anticipating that if adolescents did not desire pregnancy they would be motivated to use contraception.
Many of these programs have had minimal impact, and this may be because at least some adolescents do not perceive pregnancy as an unwanted situation. It is well-known that lack of parental involvement and lack of parental monitoring of adolescent activities are risk factors for adolescent pregnancy. Much research and study has focused on identifying biological, psychological, and social characteristics of girls who are most likely to be at risk for adolescent pregnancy. In one study, 12% of sexually active male high school students report having been involved in a pregnancy.20 However, not all boys involved in a pregnancy become fathers, because almost half of these pregnancies will end in either elective abortion or miscarriage. The younger a sexually experienced adolescent is, the more likely she is to have experienced involuntary sex.21CONTRACEPTIONAlthough an increasing percentage of adolescents are using condoms, the use of oral contraceptive pills is decreasing, thus placing many at higher risk for adolescent pregnancy. Logically, it is somewhat surprising that so many adolescents stop using oral contraceptives, given their multiple noncontraceptive benefits including decreased acne, predictable cycles, and less dysmenorrhea, among others.
We know that those sexually active girls who use effective contraception are different from those who do not. They are typically older, are in more stable relationships, have higher academic achievement, and higher educational goals than teens who do not use contraception.11 These data suggest that for prevention programs to be successful, knowledge of sexuality and contraception must be taught before the high school years. Teens must actively desire to prevent conception, and positive alternatives to pregnancy need to be stressed to help motivate adolescents to avoid pregnancy. Helping adolescents postpone sexual involvement until they are developmentally capable of effectively using contraception will also result in lower pregnancy rates.New dosing regimens and contraceptive delivery systems have become available, which may have a positive impact on compliance. Emergency contraception has become widely available, but its specific impact on adolescent pregnancy rates is not well known. IMPACT OF PRENATAL CAREYounger pregnant adolescents are less likely to access prenatal care than older adolescents, and all adolescents are less likely to seek timely prenatal care than adults9 (Figs.
In 2001, only 48% of young adolescents (younger than age 15) began prenatal care in the first trimester, compared with 70% of girls aged 15–19.
The care of the pregnant teen encompasses concerns regarding continued education, social support from family and the peer group, and the adolescent's ability to be able to provide emotional and financial support for the infant. All too frequently, teenage pregnancy is a marker for poverty, low socioeconomic status, low educational achievement, lack of goals for the future, and the developmentally normal need and desire of adolescents to express autonomy and individualism.
While the prenatal care team must provide adequate medical care, nutrition counseling, and access to social support systems (such as the nutritional information and assistance offered by the Women, Infants, and Children [WIC] Program in the USA), the greatest challenge to the team is usually found in getting the adolescent to seek prenatal care. Once prenatal care has been initiated, the challenge is to provide a network of psychological and social support to help the adolescent avoid many of the adverse sequelae associated with teenage pregnancy.
The teaching and support system specially geared toward the adolescent patient may have a positive impact on future pregnancy rates, completion of high school, economic achievement, and neonatal and childhood outcomes. Many experts on adolescent pregnancy feel that the adolescent patient (regardless of socioeconomic status) is best served in a specialized clinic setting where support from nutritionists, social workers, and prenatal educators is readily available. A team approach with awareness of the social, psychological, and biological developmental issues of adolescence is also a critical component of the care that is provided in these specialized clinics. These factors are not as easily reproducible in the average private physician's office, and specialized clinic settings are essential. There is some hope that HMOs are beginning to understand the potential value of adolescent centered pregnancy care, as evidenced by a major initiative at a Massachusetts staff model HMO, which is geared toward adolescent-friendly care with regard to confidentiality, contraceptive counseling, infection screening, and provision of postpartum birth control.35Despite recent efforts by some, most HMOs still fall short of the comprehensive care provided by most university based clinics. For example, a study in Washington State scrutinized the provision of care provided to adolescents in both Medicaid HMO plans and the care provided in traditional nonprofit staff-model plans, and found that only 27% of sexually active girls were tested for Chlamydia, with lower rates of testing in those who spoke English as a second language.36OBSTETRICAL CONCERNSIn the past, it was believed that the adolescent was too biologically immature to achieve and complete a successful, uncomplicated pregnancy. The very young adolescent, defined as within 2 years of menarche, was felt to be subfertile secondary to an immature hypothalamic-pituitary-gonadal axis and the resultant anovulatory cycles. Specifically, there was no increase in prematurity, hypertensive complications, or neonatal morbidity. They also found an increased risk for preterm and LBW babies in the youngest gravidas, even in those with the most favorable socioeconomic background, suggesting that adequate prenatal care and improvement in socioeconomic factors do not totally eliminate the medical risks of adolescent pregnancy in the youngest age group.40Increased risk for adolescents, particularly young adolescents, has been demonstrated in a recently published retrospective chart review of 25,000 deliveries, which included 2930 young adolescents, 11,788 mature adolescents, and 11,830 controls older than age 2032 (Fig. This study not only documented that pregnant adolescents were more likely to be black, diagnosed with a sexually transmitted disease, and reside with people other than their parents than were older pregnant women but also showed that risks for poor obstetric outcome differed by age of the adolescent.
The risk of preeclampsia, eclampsia, preterm delivery, LBW, and very LBW was greater in the very young adolescent, while the mature adolescent was only at increased risk of eclampsia. All adolescents were less likely to have a cesarean section or an operative vaginal delivery than were older women. Scholl and associates also noted that for multiparas younger than age 15 with a previous preterm delivery, the risk for another preterm delivery was 37%, compared with 8% for the older multipara with the same history.
No increase in adverse obstetrical or perinatal outcome has been demonstrated in the adolescent patient older than age 15 years. Some studies suggest that the young adolescent (younger than 15 years or within 3 years of menarche) is at an increased risk for LBW infants and preterm delivery. Teenagers, in general, have lower nutritional reserves than their adult counterparts, secondary to their own bodies' continued increased metabolic demands for growth and their poor diets. Adolescents within 3 years of menarche tend to have lower total weight gains during pregnancy than do older women.Obesity has reached an all time high in the United States, and excessive weight gain in adolescent pregnancy may lead to a greater risk of obesity after pregnancy.
The Institute of Medicine's recommendations for gestational weight gain in adolescents were originally published in 1990 and were reviewed in 1997.
The comment was made that although new studies are necessary, no change in recommendations was required.38 Recommendations for weight gain by BMI are shown in Table 3. It is recommended that an adolescent with a low body mass index gain amounts at the upper end of the range.
Early inadequate weight gain in the adolescent pregnancy may increase the risk for poor pregnancy outcome.
Typically, the requirements for pregnant adults are added to the nutritional requirements for nonpregnant adolescents to provide an estimate for the pregnant adolescent's daily nutritional needs. Because of the very young adolescent's continued growth demands, the daily nutritional requirements are usually placed at the upper limit of the range. The additional amount of protein needed during pregnancy is based on the amount of protein deposited in new tissues, plus the efficiency of conversion of dietary protein to tissue protein. Women who conceive during or soon after adolescence are even more likely than their adult counterparts to enter pregnancy with low or even absent iron stores.50 Iron deficiency during pregnancy is known to be associated with premature delivery, LBW and increased perinatal mortality. In addition, infants born to iron-deficient mothers have a higher prevalence of anemia in the first 6 months of life.50Adolescents who become pregnant are often in lower socioeconomic groups, have poor baseline nutrition, and are not very knowledgeable about nutrition.
One study compared pregnant women who were eligible for the Special Supplemental Nutrition Program of WIC but who were not participating in the program with those who were participating. Results showed that the longer a woman participated in WIC, the heavier her baby was likely to be at birth.
In addition, those who entered prenatal care and received WIC support before 12 weeks of gestation were 25% less likely to deliver a small-for-gestation baby.46Risk-Taking During PregnancyAdolescents are still maturing, emotionally and cognitively, and their immaturity often results in risk-taking behaviors that have serious consequences, especially during pregnancy. For an adolescent, social acceptance gained by smoking, for example, may be considered a benefit that outweighs the risk of poor pregnancy outcome. This is related in part to the fact that young adolescents are typically concrete in their thinking and not developmentally able to appreciate the future consequences of their current actions.
Chlamydia trachomatis, Neisseria gonorrhea, genital herpes, hepatitis B, syphilis, HIV, the human papilloma virus (HPV), and trichomoniasis are the most common. Because the average time between infection with HIV and the onset of AIDS symptoms is 10 years, most of the new cases of AIDS in the 20–29 age group were contracted during the teen years. Chlamydia and gonorrhea rates vary dramatically by region, and it is essential to screen adolescents during pregnancy, both at initiation of care and later in gestation to evaluate for re-infection.
Adolescents are much less likely to use condoms once they know they are pregnant, with 87% of pregnant adolescents reporting unprotected intercourse within the last 30 days, compared with 62% of matched nonpregnant controls.53Although rates of HIV infection are relatively low among adolescents, those who become pregnant may be at higher risk than other teens. Pregnancy is an excellent time to screen adolescents for HIV and provide education about HIV transmission.
HIV screening is recommended by the American College of Obstetrics and Gynecology (ACOG) for all pregnant women at initiation of care.Prenatal care for adolescents is also an excellent opportunity to provide preventative care and guidance.
Pregnant adolescents are at high risk for other STDs, and therefore should also be screened for Chlamydia, gonorrhea, HIV, and syphilis during pregnancy and should be encouraged to have the hepatitis B vaccine if nonimmune. A significant number of pregnant girls are abused by their male partners; others are victims of continuing physical abuse from parents or guardians. Twelve percent of adolescents of diverse ethnic background reported intimate partner violence during pregnancy, and even higher rates postpartum, according to a 2002 study60 (Fig.
In one study reporting prospective abuse screening, 28% percent of teens versus 23% of adult gravidas reported abuse before the pregnancy.59 Fifty percent of the patients reporting a history of abuse during the year before pregnancy would go on to experience further abuse during pregnancy, making a previous history of abuse the number one risk factor for abuse during pregnancy. While the rate of abuse was higher for teens, the intensity of abuse was greater in the adult gravidas. The association between abuse and late onset of prenatal care was demonstrated in this study.
While abuse during pregnancy was found to be a significant risk factor for delivering a LBW infant, it was a more significant associated risk factor for the adult women than for the teens. Abused teens were found to have a significantly greater risk for poor weight gain, first or second trimester bleeding, smoking, alcohol, and illicit drug use.59 Fig.
Educational attainment among pregnant adolescents varies by region and is likely affected by socio-demographic characteristics. Adolescent mothers who fail to complete high school within 5 years after birth of their first child have twice the risk of welfare dependence two decades later.63 Frequently, educational failure and withdrawal from school antedate adolescent pregnancy and may be seen as a marker for poorer educational achievement after pregnancy. Academic achievement and future aspirations before pregnancy are among the best predictors of adolescent gravidas' completion of high school after delivery.27THE ADOLESCENT MULTIPARAAdolescent mothers are at extremely high risk for repeated pregnancy while still in adolescence.
Because the adolescent multipara is at increased risk for delivering a LBW infant compared with her adult counterpart, and because many adolescent mothers are already economically disadvantaged or have social stress, it is essential to target these girls for pregnancy prevention.
Age at first birth, shorter pregnancy intervals, unmarried status, and cultural factors influence risk of subsequent pregnancy. A web browsers search on the topic teen pregnancy will link an adolescent with web sites from a variety of sources, with a multitude of messages. Some sites are misleading and offer an online pregnancy test, while others offer expert advice from adolescent parents. Although the messages and information available to adolescents is variable, many sites do offer valid and valuable information regarding nutrition, birth control, the risks of smoking during pregnancy, prenatal care options, parenting, and more.
How well adolescents will filter the information on the Internet and how well they can differentiate the high-quality sites from those with misleading messages is unknown. The Robin Hood Foundation published a report in 1996 outlining the economic and social impact of teen pregnancy in which they reported that adolescent childbearing itself costs taxpayers approximately $6.9 billion per year. Others have been fairly well studied and seem to be beneficial, or show no change in adolescent pregnancy rates. Although schools are providing information on STD prevention, HIV, abstinence, and condom use to students in lower grades than they were a decade ago, the instruction is less likely to provide information on birth control, abortion, sexual orientation, and information on how to obtain contraceptive and STD services. Abstinence-only education is gaining popularity: in 1988, abstinence-only curricula were taught by only 2% of sexuality education teachers, compared with 23% of teachers in 1999. Similar results have been found for participants in the Postponing Sexual Involvement (PSI) program, a national sexuality education initiative.72 Comprehensive age-appropriate sexuality education for kindergarten through 12th grade has been endorsed by the ACOG.
Except for the very young adolescent, age in and of itself does not appear to be a major factor in the myriad of medical and obstetric complications previously ascribed to the teen pregnancy.
The social and economic impact of teen pregnancy is great, not only for the adolescent but also for society.
It is apparent from recent data that by encouraging and providing adolescents with adequate prenatal care, most will have a positive obstetric course.
Greater emphasis is needed on providing adolescents with the skills to postpone sexual activity until they are able to practice responsible sexual behavior.The problem of adolescent pregnancy needs to be addressed with a multifaceted approach. Not only do adolescents need comprehensive sexuality education that encourages them to remain abstinent and provides instruction on appropriate use of birth control but they also need ready access to affordable contraception.
In addition, education regarding the negative consequences of adolescent parenthood, encouragement to practice healthy behaviors, and help finding emotional support are also essential.
Through a multidimensional approach to adolescent-centered preventative health, adolescents may develop the knowledge, behaviors, and self-esteem that will allow them to be motivated to prevent pregnancy through abstinence or responsible sexual behavior.
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