This issue of Pediatric Annals, with Reginald C. Tsang, MBBS, as Guest Editor addresses the challenges associated with teenage pregnancy. Dr Tsang, who is Director of Neonatology at the University of Cincinnati's Children's Hospital and Executive Director of its Perinatal Research Institute, is familiar with the adverse effects of teenage pregnancies in terms of neonatal morbidity and mortality. The authors he has enlisted are experts in their fields, which include the epidemiology and prevention of adolescent pregnancy, as well as the improvement of outcomes for these mothers and their babies. Their reports in most respects are discouraging; however, they do provide practicing physicians with the directions they need to take in counseling teenagers (and preteenagers) about their emerging sexuality, their sexual activities, and how these can be controlled to avoid the consequences of pregnancy and sexually transmitted diseases.
Simply stated, the United States has the highest teenage pregnancy, abortion, and childbirth rates among all Western countries; our pregnancy rate for those under 15 years of age is five times that of other Western countries.1 The National Research Council estimated in 1987 that 40% of white women and 64% of black women reaching the age of 20 years in 1990 will have experienced at least one pregnancy.2
Sexual activity among adolescents who use contraception inconsistently leads not only to pregnancy but also to sexually transmitted diseases and their consequences. For example:
* Very young pregnant teenagers not receiving prenatal care are more likely than older women to suffer the antepartum and postpartum complications of hypertension, anemia, and obesity.3
* Babies born to very young teenagers are more likely to be of low birth weight and to die during their first 28 days of life than babies born to older women, again because teenagers are less likely to seek prenatal care, but also because some may be 1) reproductively immature, 2) more likely to have acquired a sexually transmitted disease before or during pregnancy, which may lead to serious infection of the fetus or the neonate, 3) more likely to smoke cigarettes, drink alcohol, and use drugs, which have adverse effects on the fetus, and 4) more likely to be emotionally distressed, which may increase the risk of their delivering a low-birth-weight infant.
Short-term psychosocial problems of greater magnitude face the teenage mother who chooses to raise her baby compared with the magnitude of those faced by older single mothers and two-parent couples. These problems often include dropping out of school, chronic unemployment, poverty, social isolation, and depression. In the long-term, however, many adolescent mothers do better, graduating from high school and gaining employment. Nevertheless, children of teenage mothers are more likely to suffer from poor parenting; poor nutrition; increased illness, accidents, and hospitalizations; sudden infant death syndrome; abuse and neglect; and poor school performance.
Acquisition of sexually transmitted diseases by pregnant or nonpregnant teenagers can lead to pelvic inflammatory disease, which has the potential consequences of chronic pelvic pain, ectopic pregnancy and infertility. Of greater importance is the potential threat to the life of the teenager or her baby of infection by human immunodeficiency vims, herpes simplex virus, or hepatitis B virus.
Thus, teenage sexuality and pregnancy together present tremendously serious difficulties and have become one of our nation's most challenging dilemmas, which has been with us for many years and has increased with each passing decade. Why? There are many reasons:
* Adolescents, both male and female, mature biologically at an earlier age than they used to.
* "Adult" sexual behaviors, openly displayed on television and in motion pictures and chronicled in newspapers and magazines, send the message to adolescents that nonmarital sexual intercourse is a common and acceptable behavior.
* The use of alcohol and drugs by young adolescents has risen steadily.
* The influence of religion, schools, and community agencies on adolescent mores and activities has diminished.
* Responsible sexual behavior and the consequences of sexual intercourse often are not taught in the home, in the schools, or in community-based programs, and many persons in our society oppose sex education and the provision of contraceptual advice, as well as condoms, in schools or elsewhere in the community.
* Having sexual intercourse and having a baby are viewed by many adolescent girls as accomplishments and the only "good thing" that happens in their lives.
* There are few deterrents to having sex and getting pregnant that adolescent girls and boys understand-many of their friends and even their parents may have had similar experiences; dropping out of school doesn't mean much when so many young people who finish high school can't get jobs; and the consequences of contracting a sexually transmitted disease are difficult to comprehend and quite remote to the "do it now" or "it can't happen to me" philosophies of many adolescents.
Given this background, what can we do? Some say we should teach our teenagers to abstain from sexual activity-"Just say no!" Others say we should teach them the facts about the dangers of sexual activity-"Just know!" Still others say a bit of both approaches are needed. But who should give these messages, at what age should they begin to be given, and for how many years do they need to be given? Some of these questions are addressed in this issue of Pediatric Annals.4-6 Stout and Ktrby indicate that less than 10% of children receive comprehensive sexuality education of any kind, and only a small portion of these receive effective education.6 They point out that the evaluation of the effectiveness of these programs is complex, expensive, and suspect. Thus, it is difficult for us to know whether we are changing adolescent sexual behaviors with efforts of this sort.
What impact can practicing pediatricians have on the sexual behavior of their patients? Certainly a great deal for some adolescents, as Hardy,1 Nazarian,7 Fisher,8 and Rauh4 indicate. But not for many, because pediatricians do not have the time to do the job right, because less than 10% of adolescents go to pediatricians for health care, and because adolescents may not change their behaviors, even when they "know" they should.
The main hope for preventing adolescent pregnancies and sexually transmitted diseases is to begin education at an early age, before sexual urges overcome the logic of the messages being delivered, to ensure that our children are raised so that they feel loved and respected regardless of the number of parents in the household, and to provide our children with reasonable expectations for successful adult lives. These things should happen simultaneously in the home, in the school, and in the community. No one would bet on these things happening for all of our children, but everyone should try to make them happen for as many as possible.
1. Hardy JB. Premature sexual activity, pregnancy, and sexually transmitted diseases: the pediatrician's role as counselor. Pediatr Rev. 1988;10:69-76.
2. Hayes CD. Risking the Future: Adolescent Sexuality, Pregnancy, and Childrearing. Vol 1. Report by the Panel on Adolescent Pregnancy and Childbearing of the National Research Council. Washington, DC: National Academy Press; 1987.
3. Stevens-Simon C, McAnamey ER. Adolescent pregnancy. In: McAnamey ER, Kriepe RE, Orr DP, Comerci GD, eds. Textbook of Adolescent Medicine. Philadelphia, Pa: WB Saunders Co; 1992.
4. Rauh JL. The pediatrician's role in assisting teenagers to avoid the consequences of adolescent pregnancy. Pediatr Ann. 1993;22:90-98.
5. Howard M, Mitchell ME. Preventing teenage pregnancy: some questions to be answered and some answers to be questioned. Pediatr Ann. 1993;22:109-118.
6. Stout JW, Kirby D. The effects of sexuality education on adolescent sexual activity. Pediatr Ann. 1993:22:1 20-126.
7. Nazarian LF. Sexual behavior can the pediatrician counsel adolescents? Pediatr Rev. 1988;10:67. Commentary.
8. Fisher M. Adolescent sexuality: overview and implications for the pediatrician. Pediatr Ann. 1991;20:285-289.