Approximately 1,000,000 women less than 20 years of age become pregnant annually in the United States. Approximately 560,000 bear children, 330,000 have abortions, and the remainder sustain spontaneous abortions.1 The scope of the medical and psychosocial risks of childbearing by adolescents is becoming clearer as more data are available.
Adolescence is a unique stage of physical and psychologic growth and development, when children become adults. Pregnancy and childbearing during adolescence may carry particular risk to the mother and the child, as the adolescent may not be entirely mature. The purpose of this paper is to consider the medical and psychosocial risks of adolescent pregnancy and childbearing in the context of physical and psychologic growth and development during adolescence.
PHYSICAL GROWTH DURING ADOLESCENCE
Sexual growth of adolescent girls occurs in an orderly, sequential fashion whether they enter puberty early or late in their teenage years. The beginning of breast development and the growth of the uterus and vagina are followed within approximately a year by the maximum height spurt and within two years by the menarche,2 The onset of menarche does not signify the cessation of physical growth: adult endocrine secretory patterns may not be fully developed/"* some women still have substantial skeletal growth to complete,5 and some women still gain approximately 15 percent more lean body mass.6 Roche and Davila5 reported that a girl who had her menarche at 11.6 years grew more and for a longer period after menarche than a girl with her menarche at 15.2 years. The total stature increments after menarche were associated with the age at which menarche occurred (p. < 0.0005). We might expect medical complications to be greater for adolescents who bear children early in their physical development than for those adolescents who delay childbearing.
MEDICAL RlSK(OBSTETRIC AND NEONATAL)
Many of the early studies of the obstetric and neonatal outcome of adolescent pregnancy are difficult to interpret. Little attention was given to the specific age of the adolescents who were studied or to their race, parity, socioeconomic and marital status, or compliance with health care. Risk was thought to be due primarily to the fact that the mother was less than 20 years of age, without proper consideration for the other important variables that negatively affect obstetric and neonatal outcome. Data from more recent, bettercontrolled studies have provided a clearer picture of pregnancy outcome for adolescent mothers.
Israel and Deutschberger7 eliminated the bias of small sample size by compiling delivery data from 14 institutions. The obstetric and neonatal outcome of 3 ,995 women less than 20 years of age was compared with that of 40,709 women who were aged 20 or older. They found that women less than 18 years of age experienced greater prematurity* and perinatal death rates than older women. Racial differences were also found to be important: more nonwhite than white mothers, regardless of the mothers' age, had premature deliveries and neonatal deaths.
Wiener and Milton8 used multivariate analyses to determine the correlates of low-birth-weight deliveries. The birth certificates of 100,277 children born between 1961 and 1965 were studied. The results indicated that race, amount of prenatal care, and maternal age (less than 15 years) were independent variables that affected obstetric outcome.
A recent study in Rochester, N. Y., indicated that older adolescents who receive adequate prenatal care should not experience more obstetric and neonatal complications than adult women of the same race, parity, and socioeconomic and marital status.9 There is growing concern, however, for the obstetric and neonatal outcome of the very young adolescents. Three well-controlled studies of obstetric and neonatal outcome of very young mothers will be described.
In an early study, Battaglia and associates10 compared three groups of mothers: black adolescents 1 4 years of age or less, black adolescents aged 15 to 19, and black women of all ages. The incidence of toxemia was greater for both younger and older adolescent groups than for the general clinic population. The incidence of cephalopelvic disproportion was highest for the young adolescents, as were the prematurity rate and perinatal mortality.
More recently, Spellacy and associates11 compared the obstetric and neonatal outcome for three groups: young black adolescents aged 10 to 15, black adults aged 20 to 24, and white adults aged 20 to 24. A high frequency of toxemia was found for the young adolescent group, but because a similar frequency was also noted for black adults, the authors concluded that the high frequency of toxemia was secondary to race. There were significantly more Jow-birth-weight deliveries to the adolescent group.
Duenhoelter and colleagues12 studied the obstetric and neonatal outcome of young adolescents less than 1 5 years of age and young adults 1 9 to 25 years of age. Their results indicated that younger adolescents have a higher rate of pregnancyinduced hypertension and a greater incidence of cephalopeJvic disproportion diagnosed clinically than adults, even when the study was controlled for parity, socioeconomic status, and prenatal clinic attendance. No differences were found between groups for the average birth weight of infants and perinatal mortality.
Thus, at present, some question remains whether very young adolescents who receive adequate prenatal care experience a greater incidence of toxemia than older adolescent or adult women of similar race, parity, and socioeconomic and marital status. Most investigators agree, however, that very young adolescents bear significantly more low-birth-weight babies than older adolescents and adults of similar backgrounds.
The exact reasons why very young adolescents bear more low-birth-weight babies are unclear. Biologic immaturity of the mother may be one factor. A measure of a woman's biologic immaturity is her gynecologic age.
Gynecologic age is the difference between chronologic age at delivery and the age at menarche. Zlatnik and Burmeister,13 as well as Erkan and colleagues,14 reported that the percentage of lowbirth-weight babies was significantly greater for women who had gynecologic ages of less than two years. Zlatnik and Burmeister13 found that 13 percent of mothers who had gynecologic ages of two years or less had low-birth-weight babies, as against 6 percent of mothers who had gynecologic ages of 3 to 9. Erkan and colleagues14 reported that 31.4 percent of mothers who were 24 months postmenarchal or less had babies who weighed less than 2,500 gm., as against 16 percent of mothers who were greater than 24 months postmenarchal. These data warrant further intensive investigation.
Jekel and associates15 have shown that subsequent children born to adolescent mothers are at a higher risk for prematurity and perinatal death than the firstborn child. For the children of primigravida adolescents, the risk of perinatal death was 0.6 percent and the risk of low birth weight was 10.7 percent. Second births had a risk of perinatal death of 7.1 percent and a risk of low birth weight of 21.2 percent. Third births had a risk of 14.3 percent for perinatal death and 42.8 percent for low birth weight. While adolescents may be able to carry a first pregnancy to term, their biologic maturity may not be sufficient to maintain subsequent pregnancies.
Another major reason very young adolescents bear more low-birth-weight infants may be that they experience more gynecologic infections during pregnancy than older adolescents or adults. In addition, because of their very young age and incomplete psychologic development, they may have poor nutritional habits, smoke and drink more, and, in general, comply more poorly with prenatal health care than older adolescents and adults of similar backgrounds. Two separate articles in this series will address the issue of nutrition during pregnancy in adolescence and the perinatal, neonatal, and infancy outcome of adolescent mothers,
PSYCHOLOGIC GROWTH DURING ADOLESCENCE
Psychologic development during adolescence includes psychosocial and cognitive maturation. Psychosocial development, according to Erickson,16 entails the formation of a stable, well-organized self- identity. Identity includes clarification of "who am I?", "who am I as a sexual person?", and "who am I as a vocational person?" Full acquisition of one's identity may not be completed until late adolescence or early adulthood.
Cognitive development includes the acquisition of the ability to "think about thinking." Adolescents progress from a stage of thinking by concrete operations to a level of thinking by formal operations. Formal-operational adolescents can handle potentialities as well as actualities. The adolescent who has achieved formal operational thinking has the ability to reason abstractly and can plan effectively for contingencies.17 We would expect that the earlier an adolescent is in her psychosocial and cognitive development, the greater risk she and her baby have for adverse psychosocial consequences.
The psychosocial risks of adolescent pregnancy and childbearing can be understood best when viewed in a developmental context. While physical growth is usually completed within several years of menarche, considerable psychologic growth continues until late adolescence or even early adulthood. An adolescent who is physically capable of bearing a child may nor be emotionally capable of coping adequately with the many stresses that accompany the pregnancy and parenthood. In addition, the presence of a child may interfere with the adolescent's own psychosocial development. The responsibility for a child may restrict her dating and interpersonal relationships, her school attendance, and her ability to obtain a job. Childbearing during adolescence may have an adverse effect on the educational achievement of the mother and also on her abilities to provide adequate parenting to her child. In addition, the pregnancy may have adverse effects on both the father of the baby and the parents of the adolescent.
Education. Adolescent parents do not complete as much formal education as do youths who postpone childbearing. Moore and Waite18 analyzed data from a nationwide survey of 5 , 1 5 9 women aged 1 4 to 24. Early childbearing was found to be associated with a lower level of educational achievement, even when populations were controlled for race and socioeconomic status. The effect of adolescent parenthood was permanent. Adolescent mothers did not achieve educational levels comparable with those of their peers who had delayed parenthood.
Card and Wise19 reported on data obtained from a nationwide survey of 375,000 students. The students were initially interviewed while in the ninth grade and then again one, five, and 1 1 years after the expected year of high-school graduation. A direct correlation was found between the age at the birth of the student's first child and the amount of schooling the student completed. This was true for men as well as women. When the students were matched with a control group for race, socioeconomic status, academic aptitude, and educational expectations before the birth of the child, the same positive correlation was found. Card and Wise also found that 50 percent of adolescent mothers and 70 percent of adolescent fathers received a highschool diploma, as against 97 percent of women and 96 percent of men who were not parents by age 24. The same differences were observed when age of parenthood was compared with the percentage of subjects who completed college.
In a controlled study investigating the consequences of adolescent parenthood, Furstenberg20 found that 49 percent of teenage mothers (study group) and 89 percent of nonpregnant teenagers (control group) had completed high school at the end of a five-year study period. In addition, 10 percent of the study group and 33 percent of the control group had received some post-high-school education.
It may be that adolescents who do poorly at school and have low educational goals become pregnant so they can drop out of school. It is difficult to know what is cause and what is effect. Some adolescents may find that rearing a child does not leave the requisite time for their own education, while other adolescents drop out of school to work or to marry.
The most serious consequence of the lack of educational achievement is the long-term loss of vocational achievement. Card and Wise19 found that adolescent mothers as adults held less prestigious jobs, had lower incomes, and were less satisfied with their jobs than the control group, who had postponed childbearing. Furstenberg20 concluded that teenage parenthood results in economic disadvantage because of a disruption of formal education. Fewer than 50 percent of high-school dropouts in his study had been employed at the five-year follow-up, as against 80 percent of the students who completed high school.
While disruption of formal education is associated with lower vocational achievement, it also is associated with a higher repeat pregnancy rate. Klerman and Jekel21 and Furstenberg20 determined that return to school was their best indicator for whether adolescents would experience repeat pregnancies. Repeat childbearing during adolescence often precludes the young mother's ever finishing her education and obtaining a decent job. The recurrent pattern of repeat adolescent childbearing is potentially destructive to young mothers and their children.
Parenting. As pediatricians, one of our major concerns about adolescent pregnancy and childbearing is our fear that the baby will not receive adequate parenting. This concern is based on the assumption that since the adolescent mother is in the middle of her own psychologic development, she will not be able to adequately attend to the emotional or physical needs of her child. A young mother may lack the self-confidence and the emotional stability essential for coping with the varied problems of child rearing.
Few studies have investigated the effect of parenting by the adolescent on the child's subsequent development. There is a suggestion, based on data from the longitudinal studies by Furstenberg22 and by Oppel and Royston,23 that children of adolescent mothers perform at a lower cognitive level than children of nonadolescent mothers. There was no evidence in either study that indicated a difference between groups regarding social adjustment. Further research is needed to validate these results.
Child abuse may be a further consequence of adolescent parenting. Gil24 reviewed a random sample of 421 incidents of suspected child abuse obtained from a California central registry of child abuse from September, 1965, through mid-February, 1966. One hundred forty cases of proved child abuse were found. The ages of the abusing parents were not skewed towards the younger age groups: 8 percent of the female heads of household and 1 percent of the male heads of household were younger than 20.
While there is no clear evidence that adolescent parents abuse their children more frequently than adult parents, children of adolescent mothers may be at greater risk for neglect. The mothers* developmental immaturity and their inability to think ahead to protect their young, preoccupation with their own problems, lack of financial resources, and uncertainty between the grandmother and the adolescent mother about who has the primary child-care responsibilities may all contribute to lack of optimum emotional and physical stimulation, nutrition, or medical care in children of adolescents. Another article in this series will address the issue of child abuse and neglect among the children of adolescent mothers.
Adolescent fathers and family. The problems encountered by adolescent fathers have not been fully appreciated. During the past several years, this issue has received increasing attention in the media. Our clinical experience in an adolescentmaternity project in Rochester has demonstrated the need to make a psychosocial assessment on all adolescent fathers whose partners seek pregnancyrelated care in the project.
Most prospective fathers are under some stress, regardless of their age. Adolescent fathers, much like adolescent mothers, are vulnerable to excessive stress because they may not as yet have completed their psychologic development.
The stresses on the adolescent father appear to emanate from at least two major sources: the negative feelings of his parents and friends and the changes he perceives as occurring in his life because of the pregnancy. His parents oftentimes are disappointed and embarrassed and feel guilty about his partner's pregnancy. They may view her pregnancy as having disrupted the goals they had planned for their son. They may also feel guilty and think they were responsible for their son's fathering a child. At times the hostile feelings of the girl's parents may also be directed totally at the adolescent father.
The adolescent father may perceive drastic changes occurring in his life as a result of the pregnancy. He may think that he must marry his girlfriend, acquire a first or second job to help her financially, or spend all of his spare time with her at the expense of his own normal adolescent peer interaction. He may become confused and depressed regarding the prospect of making major life changes, the future of which is uncertain.
Many of the adolescent fathers for whom we have cared are socially isolated. They may lack the strong peer-group or family support necessary to assist them through the crisis of pregnancy. The need for emotional support can be determined through an interview with the prospective father. Appropriate follow-up, if necessary, can then be arranged.
The family of the pregnant adolescent may also need emotional support during the pregnancy. They may be stressed by their own feelings of guilt, embarrassment, or disappointment. They may have to make major financial commitments if the decision is made for the adolescent mother to keep her baby and the mother and child have no other sources of support. They may have to alter their own plans to accommodate the child in their home. Great conflict may occur within the home about who actually makes the major decisions concerning the child's needs and care and about who will care for the child when the adolescent mother returns to her adolescent activities.
Pregnancy does not occur in a void. Attempts should be made by health-care professionals to assess the emotional needs of the adolescent father and the parents of the prospective mother and father.* Intervention programs have reduced the incidence of repeat pregnancy significantly and, thus, offer adolescents the opportunities to choose other options than repeat pregnancy.9
Adolescent pregnancy and chiidbearing occur within the context of adolescent physical and psychologic growth and development. Very young adolescents, who may not be biologically mature, have a greater risk of bearing low-birth-weight babies than adolescent and adult mothers of similar backgrounds. By far, the most serious morbidity from adolescent pregnancy and chiidbearing is a result of the psychologic immaturity of adolescents, particularly the very young. Pregnancy disrupts their normal psychologic development and their education. They have poor vocational opportunities as adults. The lives of the father of the baby and the family of the mother and father may be disrupted. The risk of repeat pregnancy during adolescence, with higher morbidity than the first pregnancy, is great.
New data will help us understand the interaction of the physical and psychosocial risks of chiidbearing during adolescence. The ideal is prevention of adolescent pregnancy and chiidbearing. Dr. Greydanus discusses contraception in adolescence elsewhere in this issue.
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