Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

Almost all pediatricians who care for adolescent children have been distressed by the frequency of unwanted pregnancies among our unmarried teenage patients. We are faced with two serious problems: how to handle the unwanted pregnancies (and many of these really are unwanted and even frightening to the girls, in spite of subconscious needs) and then the larger problem of how to prevent such pregnancies in the future.

Before the days of legalized abortions, many of us knew welltrained and skilled gynecologists in various parts of the United States to whom we referred some of the girls for termination of their pregnancies. Others we referred to adoption agencies, which usually placed the teenagers in special homes during the last two or three months of their pregnancies. Friends of the family and schoolmates were often told that the girl was traveling abroad.

In my own practice of more than 50 years, I never had an unmarried teenager who desired to keep her own baby. But my practice was largely upper-middleclass, where the families of pregnant teenagers felt themselves stigmatized and the girls themselves believed they would be less desirable in future social relationships. On the other hand, I spent some time teaching in several clinics in the Harlem section of New York City, where the population was almost entirely black. Here, a good many of the pregnant teenagers kept their infants. I learned from questioning these young mothers that their families would help them care for the babies and, in a certain number of cases, the babies' fathers, families would care for the infants from time to time even though marriage between father and mother was rarely considered. These pregnant black girls did not desire their pregnancies but accepted them, realizing they had their families' support. And , as one of my friends - a leading Harlem pediatrician - informed me, there was no stigma in the black community attached to having a teenage outof-wedlock pregnancy.

The larger problem that concerns many of us pediatricians, however, is the prevention of teenage pregnancies. At first, our approach was through the teaching of sex education, on the assumption that many adolescents who had a scientific understanding of the sex act and its consequences would be deterred from taking the chance of becoming pregnant. A few reports supported the validity of this approach. Contrary to the concern often expressed by opponents of such programs, there has been no reported increase in sexual activity among teenagers as a result of these courses in sex education or as a result of the reading of wellrecognized books for the young on birth and reproduction.

I myself was closely involved in the field of sex education for years, giving courses in schools, churches, and synagogues in New York City and its suburban areas and, with my wife, writing several books and pamphlets on the subject. And so, some years ago, when I attended the International Pediatrie Congress in Copenhagen, I took time out to study the methods of sex education used in the school system in Denmark. I learned that they did things in regard to sex education that differed greatly from the approach we had been using in the United States.

For example, in addition to discussing the anatomy and physiology of the male and female reproductive systems, they demonstrated by objects and pictures the various contraceptives and methods of their use. They also insisted that the male panner use a condom during the act of intercourse. If an unmarried teenager became pregnant, the authorities inquired as to the father of the child and accepted the mother's word…

Almost all pediatricians who care for adolescent children have been distressed by the frequency of unwanted pregnancies among our unmarried teenage patients. We are faced with two serious problems: how to handle the unwanted pregnancies (and many of these really are unwanted and even frightening to the girls, in spite of subconscious needs) and then the larger problem of how to prevent such pregnancies in the future.

Before the days of legalized abortions, many of us knew welltrained and skilled gynecologists in various parts of the United States to whom we referred some of the girls for termination of their pregnancies. Others we referred to adoption agencies, which usually placed the teenagers in special homes during the last two or three months of their pregnancies. Friends of the family and schoolmates were often told that the girl was traveling abroad.

In my own practice of more than 50 years, I never had an unmarried teenager who desired to keep her own baby. But my practice was largely upper-middleclass, where the families of pregnant teenagers felt themselves stigmatized and the girls themselves believed they would be less desirable in future social relationships. On the other hand, I spent some time teaching in several clinics in the Harlem section of New York City, where the population was almost entirely black. Here, a good many of the pregnant teenagers kept their infants. I learned from questioning these young mothers that their families would help them care for the babies and, in a certain number of cases, the babies' fathers, families would care for the infants from time to time even though marriage between father and mother was rarely considered. These pregnant black girls did not desire their pregnancies but accepted them, realizing they had their families' support. And , as one of my friends - a leading Harlem pediatrician - informed me, there was no stigma in the black community attached to having a teenage outof-wedlock pregnancy.

The larger problem that concerns many of us pediatricians, however, is the prevention of teenage pregnancies. At first, our approach was through the teaching of sex education, on the assumption that many adolescents who had a scientific understanding of the sex act and its consequences would be deterred from taking the chance of becoming pregnant. A few reports supported the validity of this approach. Contrary to the concern often expressed by opponents of such programs, there has been no reported increase in sexual activity among teenagers as a result of these courses in sex education or as a result of the reading of wellrecognized books for the young on birth and reproduction.

I myself was closely involved in the field of sex education for years, giving courses in schools, churches, and synagogues in New York City and its suburban areas and, with my wife, writing several books and pamphlets on the subject. And so, some years ago, when I attended the International Pediatrie Congress in Copenhagen, I took time out to study the methods of sex education used in the school system in Denmark. I learned that they did things in regard to sex education that differed greatly from the approach we had been using in the United States.

For example, in addition to discussing the anatomy and physiology of the male and female reproductive systems, they demonstrated by objects and pictures the various contraceptives and methods of their use. They also insisted that the male panner use a condom during the act of intercourse. If an unmarried teenager became pregnant, the authorities inquired as to the father of the child and accepted the mother's word as to paternity. And, if the baby was born, the father was charged by the State for the upbringing of the child during the years that followed and through adolescence. The cost was automatically deducted from whatever salary he earned in the years that followed.

In the United States, most teenage boys reject the use of the condom as interrupting and disturbing full sexual gratification. Contraception, therefore, becomes in almost ali instances the full responsibility of the sexually active teenage girl. The pill is available today but must be prescribed by a physician who understands the safe estrogen dosage for a teenager - and it must be taken daily if it is to be effective. Diaphragms, one of the best contraceptive devices, must be fitted, and intrauterine devices must be inserted by an experienced physician. Contraceptive creams, jellies, and foams may be obtained at drug counters but for optimal protection should be used with a diaphragm or condom. Unfortunately, the vast majority of teenage girls, unless under the care of a contraceptive clinic, cannot afford the expense of full contraceptive management.

As the authors of the opening article in this issue report, about 1,000,000 young women in the United States less than 20 years of age become pregnant each year. Of these, 560,000 bear children, 330,000 have abortions, and the remainder sustain spontaneous abortions. The problem of adolescent pregnancies is today still far from being solved, in spite of all our modern scientific knowledge. Furthermore, the detrimental physical and emotional effect they have on both mother and child are well recognized. Studies have demonstrated that there is increased prematurity and increased perinatal mortality among the infants of teenage mothers.

But the physical effects on the unborn infants are only one of the factors in adolescent pregnancies. The psychosocial effect on the young mother, the potential hardships that He ahead for both mother and child, must also be considered, as must the continuing effort that has to be made if unwanted pregnancies are to be prevented in the future. It is with all these problems in mind that this issue of PEDIATRIC ANNALS was planned to focus on the difficult problems inherent in adolescent pregnancy.

The guest editor for the symposium is Dr. Elizabeth R. McAnarney, Associate Professor of Pediatrics and director of the Division of Biosocial Pediatrics and Adolescent Medicine at the University of Rochester School of Medicine and Dentistry in Rochester, N. Y. Dr. McAnarney is recognized as a national authority on the subject of adolescent pregnancy; she has conducted extensive studies in this field, published articles in pediatrie journals, lectured, and conducted seminars on the problem at the conventions of the American Academy of Pediatrics.

Dr. Arthur B. Elster, of the University of Utah Medical Center, in Salt Lake City, joins with Dr. McAnarney in presenting the first article in the symposium, "Medical and Psychosocial Risks of Pregnancy and Childbearing During Adolescence." These writers deal first with the medical problems of the mother and infant during the prenatal and neonatal periods. Various opinions regarding the cause of low-birthweight pregnancies are presented. The second portion of their discussion considers the psychosocial risks childbearing brings to adolescent mothers, focusing especially on the forced lack of educational achievement childbearing will entail and the resulting loss in vocational achievement in the future because of this. Parenting is also considered; the authors observe that there is no evidence of an increased incidence of child abuse by these teenage mothers, but there is a greater possibility that their infants will suffer neglect.

The second article in this symposium, "Nutrition of the Pregnant Adolescent," comes from the Department of Pediatrics at the University of Maryland School of Medicine in Baltimore and has been contributed by Dr. Felix P. Heald, Professor of Pediatrics and director of the Division of Adolescent Medicine, and Dr. Marc S. Jacobson, Assistant Professor of Pediatrics and assistant director of the Division of Adolescent Medicine. This is a careful and scientific study of the nutritional needs that adolescent mothers must satisfy if their infants are to have adequate growth during their fetal period. The reasons why pregnant teenagers may tend to have poor nutrition are examined, including the possibility of poor economic conditions of their families and the desire of some young mothers to restrict their weight. Since pediatricians usually follow and control adolescent care, the problem of adequate nutrition for the fetus becomes a pediatrie rather than an obstetric problem in teenage pregnancy . These authors provide useful directions for the pediatrician who is faced with the nutritional care of a pregnant teenager.

"The Infants of Adolescent Mothers," the third article in this issue, is an important collaborative study of more than 60,000 pregnancies focusing on the perinatal, neonatal, and infancy outcome of babies born to teenage mothers. This careful study has been reported by Drs. T. Alien Merritt and Ruth A. Lawrence, of the Departments of Pediatrics and Obstetrics-Gynecology at the University of Rochester School of Medicine, and by Dr. Richard L. Naeye, Professor of Pathology at the Pennsylvania State University Hershey School of Medicine. Included in this study are data from almost 56,000 pregnancies from the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, carefully analyzed by Dr. Naeye. Also studied are data concerning 4,000 pregnancies at the University of Kansas Medical Center and 6,087 at the Regional Perinatal Center at the University of Rochester.

The results reported in this article will be of the greatest interest to pediatricians. It would appear that although there is a higher incidence of cigarette smoking, alcohol and drug abuse, and early and prolonged rupture of the membranes among teenage mothers than in older mothers, the determining factor in effecting low birth weight among infants born to adolescents is the shorter gestational age of many of these infants.

These authors also present a study of perinatal mortality, as well as a study of neonatal complications. They discuss causes of infant morbidity and mortality and the long-range outcome for infants born to teenage mothers, including their physical development, I.Q., and later academic achievement. The article concludes with a discussion of maternal behavior of teenage mothers.

The fourth contribution, "Contraception in Adolescence: An Overview for the Pediatrician," has been written by Dr. Donald E. Greydanus, director of the Adolescent Medical Clinic at Strong Memorial Hospital at the University of Rochester. Dr. Greydanus discusses oral contraceptives at the outset and recommends the doses best given to teenagers to avoid or reduce pill side effects. He believes that thromboembolism is highly unlikely in a teenager (especially if there is no history of smoking) and states that there is no evidence that combined oral contraceptives cause cancer. He presents and discusses contraindications. Among other contraceptives discussed in detail are the intrauterine devices, such barrier methods as the diaphragm and condom, vaginal contraceptives, and injectable contraceptives. Brief mention is made of the rhythm method, coitus interruptus, and the douche. This paper should be of great value to all pediatricians who treat sexually active teenagers.

The fifth paper, "Adolescent Parenting: Potential for Child Abuse?" has been written by Dr. Olle Jane Z. Sanier, Assistant Professor of Pediatrics and Psychiatry at the University of Rochester School of Medicine. The author discusses some of the motivations a teenage girl may have that can lead to pregnancy and notes that both the girl's reasons for becoming pregnant and her family's response will have some definite influence on her future conduct as a parent. Dr. Sahler notes, however, that no factor can conclusively determine the girl's potential for good or inadequate motherhood. In regard to the possibility that a teenage mother may become an abusive or neglectful parent, Dr. Sahler observes that there are so many variable influences that lead to abuse and neglect that the question regarding teenagers is still open. Much more study will be necessary before any conclusions can be reached. ?

10.3928/0090-4481-19800301-03

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