Adolescent pregnancy continues as one of the major medical/social problems of our time. Its epidemiology and demography are wellknown and described elsewhere in this issue of Pediatric Annals.1 Albeit all adolescents are at some risk for becoming a teenage parent, those teenagers most at risk in the United States are young, black or Hispanic, and poor. The purpose of this article is to briefly mention the medical and social sequelae of adolescent pregnancy and then to suggest ways that pediatricians can assist with outcome and prevention. Real-life situations and opportunities that confront practicing pediatricians will be emphasized.
Premature delivery often represents a tragic, final, common pathway of adverse outcomes for any combination of one or more of the risk factors listed in Table 1. Davidson and Felice2 summarized the consequences of premature delivery during adolescence in this way:
Young adolescents, those less than 15 years of age, have a higher risk for premature delivery (before 37 weeks) and delivery of low birth weight (LBW <2500 g) infants. Black teens in this age group have the highest neonatal mortality rate, almost double the national average of 7.6 in 1000 live births. Young adolescents are also more likely to have infants who are born weighing <2500 g (14% of births to teens vs 6% of births to women ages 25 to 29).
The association between young age at pregnancy and perinatal outcome is not necessarily related to biologic factors. Demographic and social variables also play a significant role in determining the pregnancy risk for rhe adolescent.
With early and comprehensive prenatal care, the risk for premature delivery or LBW infants among adolescents is greatly reduced. Some studies have shown that with repeat teenage pregnancy there is an increased risk of neonatal mortality and LBW infants. Orher studies have noted similar rates of LBW infants despite the interval between pregnancies.
Comprehensive prenatal care is essential to a good outcome for the pregnant teenager. The setting should be interdisciplinary and usually includes an obstetrician, pediatrician, nutritionist, social worker, and a nurse practitioner. This setting, which may vary from a traditional obstetrics clinic to a joint obstetric-pediatric/adolescent medicine facility to a school-based clinic, is not as crucial as the need for a staff that is sensitive to the special needs of adolescents.
Risk Factors for Premature Delivery
5-Year Follow-up of 100 Pregnant Unmarried Teenagers*
Davidson and Felice2 also emphasize the critical importance of nutritional assessment and support services since poor nutritional habits at this age contribute to increased nutritional difficulties during pregnancy. They further state, "Poor weight gain (less than 24 to 28 lbs) during pregnancy contributes to having a LBW infant. Caloric intake should be between 2400 and 2700 cal/day. Protein intake must be increased to about 75 g/day. Multivitamins with iron supplementation of 30 to 60 mg/day of iron salts are also necessary."2
Although it has been 26 years since Sarrel and Davis3 published their classic study of the outcome of 100 pregnant ummarried teenagers in New Haven, Connecticut, their findings are still relevant to such outcomes today. They looked at a 5-year follow-up of 100 unmarried teenagers ages 17 or less who delivered within a 2-year period. The results are summarized in Table 2. They found that 90% to 95% of their primiparous teenager cohort had at least one repeat pregnancy, remained on welfare, and had little chance of finishing high school or becoming self-sufficient. It must be noted that this study was done before abortion became legal and at a time when contraception for teenagers was quite limited. The authors emphasized the need for contraception as well as total patient care for their high-risk population and later had much improved outcomes when such services were provided.4 Only 5% of deliveries to 119 teenagers cared for by the Yung Mothers Program of the Yale-New Haven Medical Center were LBW, and more than 90% avoided pregnancy for at least 1 year postpartum.4
Furstenberg and colleagues5 have written extensively on the adolescent and later life experiences of Baltimore teenage mothers and their firstborn children based on 17 years of follow-up from 1967 to 1984. As abortion and contraception became more available, a substantial majority of Baltimore high-risk young mothers in the study eventually completed high school, found regular employment, and managed to escape from public assistance.
It is noteworthy that adolescents attending a special school for pregnant teens in Baltimore, as in New Haven, were more likely to be economically well off and have fewer children in adulthood than women who either dropped out or remained in a regular school program. Attendance at the special school reduced the likelihood of remaining on welfare in half Our experience in Cincinnati replicated such findings in New Haven, Baltimore, and many other cities, ie, comprehensive multiservice prenatal care, begun early, and effective contraception postpartum can significantly reduce the incidence of prematurity, obstetric complications, and repeat pregnancies.
In the late 1960s, the Adolescent Clinic at Cincinnati General Hospital compared a group of pregnant teenagers given multidisciplinary comprehensive prenatal care and family planning after delivery with a matched group coming to the adult maternity service who received no special consideration.6 Both groups were delivered by the hospital's obstetric staff The intervention group had significantly less prematurity than the control group (8% versus 19%); less obstetric complications, especially preeclampsia (70% versus 30%); and less repeat pregnancies when they were followed for at least 2 years postpartum and were provided appropriate contraception (75% versus 25%). Few physicians go into pediatrics to care for adolescents, let alone devote themselves to preventing the obstetric and psychosocial sequelae of adolescent pregnancy. Although pediatricians see approximately one third of young American teenagers ages 11 through 14 in a private ambulatory setting, they only encounter 8% of 15 to 20 year olds.7 On the other hand, adolescent medicine training is now required by the Residency Review Committee for Pediatrics of the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. An increasing number of young pediatricians are being exposed to the necessary components of comprehensive prenatal care and effective family planning services for high-risk teenagers. In 1990, the Residency Review Committee stated that "Pediatric residents must have patient care experiences in health maintenance examination, family planning, sexually transmitted infections, and gynecology." The American Academy of Pediatrics continues to emphasize the responsibility pediatricians have to care for adolescents and to provide preventive education to teenagers, parents, and the community.
The following case vignettes illustrate how the practicing pediatrician who has some training as well as motivation and interest in these problems can have an impact on adolescent pregnancy.
SHIFTING GEARS FOR ADOLESCENTS
You have just finished your pediatric residency and have joined a private practice group. You enjoyed your adolescent medicine training during residency and volunteer to see the teenagers in the practice. What can you do to help your adolescent patients, especially those 16 years of age and younger, postpone sexual activity? What is optimal care for a teenage female to preserve her fertility, regardless of the age of first pregnancy?
Every pediatrician needs to "shift gears" with his or her young teenagers and provide some time alone with these patients. This is harder to accomplish with patients whom you have known from birth or early childhood. So this shift in focus and style allowing direct and private communication with an adolescent may be much easier for you than your already established, older practice partners.
As a rule of thumb, I recommend that when your patient reaches Tanner Stage 2, around the age of 12 years, explain to her and her mother that you want to see the daughter alone and then explain your philosophy and rules about confidentiality.
A helpful schema for adolescent history-taking is using the acronym HEADS (Table 3). This listing reminds you to ask questions that should elicit medical problems related to home, school, peer activities, etc. Preface questions that make you uncomfortable, such as "Have you ever had sex?," with "You know, it's important that I know more about your life and behavior, like sex, in order to take care of you." Teenagers appreciate such candor and directness regardless of the provider's gender. As time permits and the history indicates, you can provide information to the patient about pubertal development, risks of sexually transmitted diseases (STD), and postponement of sexual activity. Careful follow-up to problems elicited from the "HEADS" history-taking, such as school failure or depression, will be critical to your success with adolescents.
HEADS Social History
Your physical examination must include a pelvic exam with cultures and a Pap smear if the adolescent has a history of sexual activity. The early detection of congenital anomalies of the genital tract, STD, or pregnancy itself will positively affect future obstetric outcome regardless of the girl's decision to continue or terminate pregnancy. A complete blood count and urinalysis are valuable to detect chronic problems such as iron deficiency anemia and chronic renal disease.
PRIVACY FOR THE PREGNANT TEENAGER
You are a pediatrician in private practice. Nancy, 16 years, has been your patient since infancy. You know her parents well and frequently socialize with them. For the past 2 years, Nancy has been coming on her own for her annual check-ups and other minor health needs with her parents' concurrence. Usually the parents know of the appointment, and you call them after the visit to tell them of your findings and recommendations. They also have promptly paid all your bills, which you customarily itemize.
This particular visit is different. Nancy seems very agitated. Ultimately she expresses her fears that she is 2 months pregnant. She had been taking birth control pills prescribed by Planned Parenthood but stopped taking them 6 months ago. You confirm pregnancy by examination and urine test. Nancy wants an abortion and is committed to her decision. After thoroughly discussing this and her other options with her, you are convinced that the girl's choice to terminate her pregnancy was made in a thoughtful, rational, and mature manner.
Although you attempt to encourage Nancy to involve her parents, she is adamantly opposed. She asks that you neither call them nor send a bill, and offers to pay you $25, which she has saved. As she leaves, however, she does let you know that her mother is aware that she was coming to see you today. This was necessary to explain why she was not at home right after school as expected. Nancy further tells you that she "trumped up" the excuse of needing to have a physical examination form completed for her gymnastics class.
Regardless of one's personal views on abortion, this situation makes physicians very uncomfortable. Let me suggest a "road map" for helping Nancy. First, you need to know what your state's statutes and common laws are in regard to consent and confidentiality for minors who are pregnant and seek abortion.8,9 Every state now has a self-consent law for the diagnosis and management of STD, which permits your initial examination. More important, Nancy's parents have encouraged her to come to you on her own, so you have some time, however brief; to assist her according to her wishes. However, 36 states today have a statute that requires any physician performing an abortion on a minor to seek consent from and/or notify one or both parents.* If the state requires notification, it must also provide a judicial bypass alternative for those teenagers who refuse to allow notification. The US Supreme Court has upheld the constitutionality of parent notification statutes for Minnesota, Ohio, and Pennsylvania in 1990 and 1992.
Nancy needs to know how the law will affect her. You and she need to discuss if and how long this matter can remain confidential. If you are uncomfortable providing her further privacy and guidance, you need to explain this and refer Nancy to another physician or facility who can serve her needs promptly and effectively.
You are a pediatrician in an urban public health clinic and are comfortable caring for adolescents. Joyce, 18 years old and on Medicaid, has two children, both bom prematurely and with low birth weight. She has had difficulty complying with prenatal care as well as oral contraception in the past. She is asking about Norplant implants and whether this is a feasible contraceptive method for teenagers.
Yes, Norplant has been well-received by teenagers since it first was marketed in the spring of 1991.10 In the Cincinnati Adolescent Clinic, we have inserted Norplant capsules in 90 patients since June 1991 and have only needed to remove them in one patient. We have had no pregnancies, high patient satisfaction, and less change in menstrual bleeding than we anticipated.
Joyce desperately needs reliable contraception. She is a "patient failure" with birth control pills and is at very high risk for a third pregnancy. Joyce can ill afford to have more children until she is more self-supporting.
In the 1960s and early 1970s, our clinic had considerable success with intrauterine devices, but they are now absolutely contraindicated for teenagers because of the risk of pelvic inflammatory disease and infertility. Our patient failure rate with oral contraceptives is 15% to 20%. Few young teenagers can comply with barrier methods. Depo-provera, a longacting injectable contraceptive, has been used as a contraceptive for years even though it lacked approval of the Food and Drug Administration until late 1992 and invariably causes secondary amenorrhea after 6 to 12 months.
The pediatrician who sees teenagers like Joyce needs to know what birth control methods are most effective, how to prescribe them, or where to refer if he or she is not able to provide them.
SCHOOL AND COMMUNITY SERVICES
You are a pediatrician in an urban community of 200 000 people. The community has a significant poor, black population and a high rate of adolescent pregnancy. You, your wife, and children are involved in many community activities, and you were elected to the board of education last year. Your mayor and board president ask you to develop a broad-based community task force to assess various school-based and community services nationwide for the management and prevention of adolescent pregnancy. You review the literature, speak with a number of experts, and identify several exemplary programs. What are they? How appropriate and feasible are they for your company? What has the experience been in Cincinnati?
Cincinnati is a moderate-sized metropolitan area with a strong conservative but generally progressive influence and tradition. Approximately 40% of the Cincinnati area is Catholic. Cincinnati Public Schools is the largest district in the area, serving 52 000 students, 65% of whom are African American, and 35% white. The percentage of other minorities is negligible.
For 15 years, from 1966 to 1981, Cincinnati Public Schools provided a special school for pregnant girls. Attendance was voluntary, but almost all pregnant junior high school students used it during their prenatal and immediate postpartum months. The school allowed the young pregnant teenager to continue her education, receive comprehensive prenatal care and delivery at the nearby University Hospital, and receive social services and health education, including family planning instruction, during the prenatal months. Such "pregnancy schools" were in vogue and much more numerous in the 1960s and 1970s; few remain today largely because of lack of funds and concern that they racially and socially isolate pregnant students. The Cincinnati school was successful and notable for its contribution to improved obstetric outcome and decreased rate of recidivism as described above. Louisville, Kentucky's Teenage-Parent Program11 has continued since 1970 as an exemplary example of how these programs can improve health, use of contraception, and school attendance. In the author's opinion, the pregnancy school is the best model for preventing adverse outcomes for girls 16 years or younger who continue their pregnancies.
In 1990, Cincinnati Public Schools initiated Postponing Sexual Involvement (PSI), the Atlanta-based program described elsewhere in this issue of Pediatric Annals,12 which teaches young adolescents to resist media and peer pressures to have early, inappropriate sexual involvement. Postponing Sexual Involvement had been a major recommendation of the Mayor's Task Force on Adolescent Pregnancy in 1986. The author and Dr Reginald Tsang, Guest Editor of this issue of Pediatric Annals on adolescent pregnancy, led an ad hoc group of business leaders, school officials, and other representatives from Children's Hospital Medical Center who found private funding and crafted a partnership between the Medical Center and Cincinnati Public Schools.
We chose PSI because of its use of older peer leaders who are trained to teach young teens and because of its emphasis on abstinence until the teenager is mature enough to make responsible decisions about sexual activity. Cincinnati PSI is currently in its third year serving 4000 seventh grade students as well as several thousand fifth graders who receive a curriculum appropriate for their age taught by the classroom teacher. It should be noted that Cincinnati's Catholic schools have used the PSI curriculum in their junior high schools since 1986, although it is taught by the classroom teacher rather than by peers. Programs such as Sex Respect and Teen-Aid from Spokane, Washington were not chosen by the Cincinnati Public Schools/Medical Center alliance because their philosophy, especially for urban populations,13 was viewed as less realistic.
Cincinnati PSI has been extremely well-received by students, parents, teachers, and the general community. Evaluation is in progress to determine if students receiving PSI in Cincinnati, like Atlanta,13 postpone sex and experience less pregnancies.
There are ways in which the practicing pediatrician can help adolescents prevent pregnancy or improve the outcome of pregnancy. Clearly, each practitioner will have to decide what services will work best within his or her practice as well as for the community.
1. Alexander CS, Guyer B. Adolescent pregnancy: occurrence and consequences. Pediatr Ann. 1993;22:85-88.
2. Davidson NW, Felice ME. Adolescent pregnancy. In: Friedman SB, Fisher M, Schonberg SK, eds. Comprehensive Adolescent Health Care. St Louis, Mo: Quality Medical Publishing; 1992:1026-1040.
3. Sarrel PM, Davis CD. The young unwed primipara: a study of 100 cases with 5 year follow-up. Am J Obstet Gynecol. 1966;95:722-725.
4. Sarrel PM, Klerman LV. The young unwed mother. Am J Obstet Gynecol. 1969;105:575-578.
5. Furstenberg FF Jr, Brooks-Gunn J, Morgan SP. Adolescent Mothers in Later Life. New York, NY: Cambridge University Press; 1987.
6. Rauh JL, Johnson LB, Burket RL. The management of adolescent pregnancy and prevention of repeat pregnancies. HSMHA Health Reports. 1971;86:66-73.
7. Irwin CE. Why adolescent medicine? J Adolesc Health Care. 1986;7:2S-12S.
8. English A. Treating adolescents: legal and ethical considerations. Med Clim North Am. 1990;74:1097-1112.
9. Henshaw SK, Kost K. Parental involvement in minors' abortion decisions. Fam Plann Perspect. 1992;24:196-213.
10. Frank ML, Poindexter AN, Johnson ML, Bateman L. Characteristics and attitudes of early contraceptive implant acceptors in Texas. Fam Plann Perspeet. 1992;24:208-213.
11. Lavery JP, Chaffee G, Marcell CC, Martin S, Reece K. Pregnancy outcome in a comprehensive teenage-parent program. Adolescent and Pediatric Gynecology. 1988;1:34-38.
12. Howard M, Mitchell ME. Preventing teenage pregnancy: some questions to be answered and some answers to be questioned. Pediatr Ann. 1993;22:109-118.
13- Howard M. Delaying the start of intercourse among adolescents. In: Adolescent Medicine: State of the Art Reviews. 1992;3:181-193.
Risk Factors for Premature Delivery
5-Year Follow-up of 100 Pregnant Unmarried Teenagers*
HEADS Social History