Epidemiology

In 2006, there were approximately 442,000 births in the USA to young women under the age of 20 yr. This figure represents a birthrate of 41.9 births per 1,000 young women ages 15-19 yr and is a 3% increase over the birthrate in 2005 (40.5). This is the 1st time in the last 15 yr that teen birthrates have increased in the USA.

Before 2006, adolescent birthrates in the USA had steadily decreased since the early 1990s for all ages, races, and ethnic groups (Table 112-1), with the most dramatic decreases noted in African-American teens. In spite of the 3% increase from 2005 to 2006, the 2006 birthrate for teens ages 15-19 yr is considerably lower than the 1991 rate of 61.8. Pregnancy rates, which include births, miscarriages, stillbirths, and induced abortions, also decreased during this time frame, indicating that the decline in birthrates was not due to an increase in pregnancy terminations. The improvement in U.S. teen birthrates is attributed to 3 factors: more teens are delaying the onset of sexual intercourse, more teens are using some form of contraception when they begin to have sexual intercourse, and there is increased use of the new, long-lasting hormonal contraceptives.

In spite of the decrease in teen births in the last decade, the USA has the highest teen birthrate among all industrialized countries. U.S. teen birthrates are twice the rates in Great Britain and Canada and nearly 4 times the rates in France and Sweden. Two thirds of teen births are to 18-19 yr old women who technically have reached the age of majority.

Etiology

In industrialized countries with policies supporting access to protection against pregnancy and sexually transmitted infections (STIs), older adolescents are more likely to use hormonal contraceptives and condoms, resulting in lowered risk of unplanned pregnancy. Younger teenagers are likely to be less deliberate and logical about their sexual decisions and their sexual activity is likely to be sporadic or even coercive, contributing to inconsistent contraceptive use and a greater risk of unplanned pregnancy. Better hopes for employment and higher educational goals are associated with lowered probability of childbearing. In nonindustrialized countries, laws permitting marriage of young and mid-adolescents, poverty, and limited female education are associated with increased adolescent pregnancy rates.

Clinical Manifestations

Adolescents may experience the traditional symptoms of pregnancy: morning sickness (vomiting, nausea that may also occur any time of the day), swollen tender breasts, weight gain, and amenorrhea. Often the presentation is less classic. Headache, fatigue, abdominal pain, dizziness, and scanty or irregular menses are common presenting complaints.

In the pediatric office, some teens are reluctant to divulge concerns of pregnancy. Denial of sexual activity and menstrual irregularity should not preclude the diagnosis in face of other clinical or historical information. An unanticipated request for a complete checkup or a visit for contraception may uncover a suspected pregnancy. Pregnancy is still the most common diagnosis when an adolescent presents with secondary amenorrhea.

Diagnosis (Table 112-2)

On physical examination, the findings of an enlarged uterus, cervical cyanosis (Chadwick sign), a soft uterus (Hegar sign), or a soft cervix (Goodell sign) are highly suggestive of an intrauterine pregnancy. A confirmatory pregnancy test is always recommended, either qualitative or quantitative. Modern qualitative urinary detection methods are efficient at detecting pregnancy, whether performed at home or in the office. These tests are based on detection of the beta subunit of human chorionic gonadotropin (HCG). While claims for over-the-counter home pregnancy tests may indicate 98% detection on the day of the 1st missed menstrual period, sensitivity and accuracy vary considerably. Office or point of care tests have increased standardization and generally have increased sensitivity, with the possibility of detecting a pregnancy within 3-4 days after implantation. However, in any menstrual cycle, ovulation may be delayed and in any pregnancy, the day of implantation may vary considerably as may rate of production of HCG. This variability, along with variation of urinary concentration, may affect test sensitivity. Therefore, each negative test should be repeated in 1-4 wk if there is a heightened suspicion of pregnancy. The most sensitive pregnancy detection test is a serum quantitative beta HCG radioimmunoassay in which results are reliable within 7 days after fertilization. This more expensive test is used primarily during evaluations for ectopic pregnancy, to detect retained placenta after pregnancy termination, or in the management of a molar pregnancy. It is generally used when serial measurements are necessary in clinical management.

Though not generally used for primary diagnosis of pregnancy, pelvic or vaginal ultrasound can be used to detect and date a pregnancy. Pelvic ultrasound will detect a gestational sac at about 5-6 wk (dated from last menstrual period) and vaginal ultrasound at 4.5-5 wk. This tool may also be used to distinguish diagnostically between intrauterine and ectopic pregnancies.

Pregnancy Counseling and Initial Management

After the diagnosis of pregnancy is made, it is important to begin addressing the psychosocial, as well as the medical, aspects of the pregnancy. The patient’s response to the pregnancy should be assessed and her emotional issues addressed. It should not be assumed that the pregnancy was unintended. Discussion of the patient’s options should be initiated. These options include (1) releasing the child to an adoptive family, (2) electively terminating the pregnancy, or (3) raising the child herself with the help of family, father, friends, and/or other social resources. Options should be presented in a supportive, informative, nonjudgmental fashion; they may need to be discussed over several visits for some young women. Physicians who are uncomfortable in presenting options to their young patients should refer their patients to a provider who can provide this service expeditiously. Pregnancy terminations implemented early in the pregnancy are generally less risky and less expensive than those initiated later. Other issues that may need discussion are how to inform and involve the patient’s parents and the father of the infant; implementing strategies for insuring continuation of the young mother’s education; discontinuation of tobacco, alcohol, and illicit drug use; discontinuance and avoidance of any medications that may be considered teratogenic; starting folic acid, calcium, and iron supplements; proper nutrition, and testing for STIs. Especially in younger adolescents, the possibility of coercive sex (Chapter 113) should be considered and appropriate social work/legal referrals made if abuse has occurred, though most pregnancies are not a result of coercive sex. Patients who elect to continue their pregnancies should be referred as soon as possible to an adolescent-friendly obstetric provider.

Characteristics of Teen Parents

Young women who become parents as teenagers often come from economically disadvantaged families. Although birthrates among black and Hispanic teens have decreased in the past decade, their rates are more than double those for non-Hispanic whites. Parenting teens frequently have poor school performance prior to becoming pregnant, and they often have a family history of low educational attainment. Learning disabilities are not uncommon. Teen mothers frequently come from single-parent families where their own mother gave birth during adolescence. A large majority (84%) of teen mothers have a baby outside of marriage. They may view pregnancy as having a positive social value and as not interfering with their long-term goals.

Teenage men who become fathers as adolescents also have poorer educational achievement than their age-matched peers. They are more likely than peers to have been involved with illegal activities and with the use of illegal substances. Adult men who father the children of teen mothers are poorer and educationally less advanced than their age-matched peers and tend to be 2-3 yr older than the mother; any combination of age differences may exist. Younger teen mothers are more likely to have a greater age difference between themselves and the father of their child, raising the issue of coercive sex or statutory rape (Chapter 113).

Male partners have a significant influence on the young woman’s decision/desire to become pregnant and to parent her child. Sensitively and appropriately including the male partner in discussions of fertility planning, contraception, and pregnancy options may be a useful strategy in improving outcomes for all.

Medical Complications of Mothers and Babies

Although pregnant teens are at higher than average risk of some complications of pregnancy, most teenagers have pregnancies that are without major medical complications, delivering healthy infants. The miscarriage/stillbirth risk for adolescents is estimated at 15% and the pregnancy termination rate has been fairly stable at approximately 33% since 1995. As expected, teen mothers have low rates of age-related chronic disease (diabetes or hypertension) that might affect the outcomes of a pregnancy. They also have lower rates of twin pregnancies than older women. They tolerate childbirth well with few operative interventions. However, as compared with 20-39 yr old mothers, teens have higher incidences of low birthweight infants, preterm infants, neonatal deaths, passage of moderate to heavy fetal meconium during parturition, and infant deaths within 1 yr after birth. The highest rates of these poor outcomes occur in the youngest and most economically deprived mothers. Gastroschisis, though very rare, has a markedly higher incidence in infants of teen mothers for reasons that are not yet clear. Teen mothers also have higher rates of anemia, pregnancy-associated hypertension, and eclampsia, with the youngest teens having rates of pregnancy-associated hypertension 40% higher than the rates of women in their 20s and 30s. The youngest teens also have a higher incidence of poor weight gain (<16 lb) during their pregnancy. This correlates with a decrease in the birthweights of their infants. Poor maternal weight gain also correlates strongly with teens’ late entrance into prenatal care and with inadequate utilization of prenatal care. Sexually active teens have higher rates of STIs than older sexually active women.

Many young women who become pregnant have been exposed to violence or abuse in some form during their lives. There is some evidence that teenage women have the highest rates of violence during pregnancy of any group. Violence has been associated with injuries and death as well as preterm births, low birthweight, bleeding, substance abuse, and late entrance into prenatal care. An analysis of the Pregnancy Mortality Surveillance System indicates that from 1991 to 1999, homicide was the 2nd leading cause of injury-related deaths in pregnant and postpartum women. Women ages 19 yr and younger had the highest pregnancy-related homicide rate (Chapter 107).

Prematurity and low birthweight increase the perinatal morbidity and mortality for infants of teen mothers. These infants also have higher than average rates of sudden infant death syndrome (Chapter 367), possibly because of less use of the supine sleep position, and are at higher risk of both intentional and unintentional injury (Chapter 37). One study shows the risk of homicide to be 9 to 10 times higher if a child born to a teen mother is not the mother’s firstborn as compared with the risk to a firstborn of a woman age 25 yr or older. The perpetrator is often the father, stepfather, or boyfriend of the mother.

After childbirth, depressive symptoms may occur in as many as 40-50% of teenaged mothers. Depression seems to be greater with additional social stressors and with decreased social supports. Support from the infant’s father and the teen’s mother seems to be especially important in preventing depression. Pediatricians who care for parenting teens should be sensitive to the possibility of depression as well as to inflicted injury to mother or child; appropriate diagnosis, treatment, and referral to mental health or social agencies should be offered and facilitated.

Psychosocial Outcomes/Risks for Mother and Child

Contraceptive counseling Encourage breast-feeding Support breast-feeding in home, work, and school settings Encourage high school completion   Assess risk of domestic violence   Encourage adolescent parenting Work with other involved adults such as grandparents to encourage developmental growth of adolescent as parent as well as optimize infant developmental outcomes Adapt counseling to developmental level of adolescent Awareness and monitoring of developmental progression of infant and adolescent parent Provide positive reinforcement for success

From Beers LAS, Hollo RE: Approaching the adolescent-headed family: a review of teen parenting, Curr Probl Pediatr Adolesc Health Care 39:215–234, 2009.

Behavioral, Educational, and Social Outcomes of Infants

Many infants born to teen mothers have behavioral problems seen as early as the preschool period. Many drop out of school early (33%), become adolescent parents (25%), or, if male, are incarcerated (16%). Explanations for these poor outcomes include poverty, parental learning difficulties, negative parenting styles of teen parents, maternal depression, parental immaturity, poor parental modeling, social stress, exposure to surrounding violence, and conflicts with grandparents, especially grandmothers. Continued positive paternal involvement throughout the child’s life may be somewhat protective against negative outcomes. Many of these poor outcomes appear to be due to the socioeconomic/demographic situation in which the teen pregnancy has occurred, not solely to maternal age. Even when socioeconomic status and demographics are controlled, infants of teen mothers have lower achievement scores, lower high school graduation rates, increased risk of teen births themselves, and, at least in Illinois (where records include age of birth mother), a higher probability of abuse and neglect.

Comprehensive programs focused on supporting adolescent mothers and infants utilizing life skills training, medical care, and psychosocial support demonstrate, at least in the short term, higher employment rates, higher income, and less welfare dependency in adolescents exposed to the programs. These may be helpful in improving the infants’ outcomes.

Prevention of Teen Pregnancies

Adolescent pregnancy is a multifaceted problem that requires multifactorial solutions. The provision of contraception and education about fertility risk from the primary care physician is important, but insufficient to address the problem fully. Family and community involvement are also needed. Strategies for primary prevention (preventing 1st births) are different from the strategies needed for secondary prevention (preventing 2nd or more births).

Abstinence-only sexual education aims to teach adolescents to wait until marriage to initiate sexual activity but unfortunately does not mention contraception. Abstinence education is sometimes coupled with “virginity pledges” in which teenagers pledge to remain abstinent until they marry. Other educational programs emphasize HIV and STI prevention and in the process prevent pregnancy, while others include both abstinence and contraception in their curricula. Sex education and teaching about contraception do not lead to an increase in sexual activity. Teenagers who participate in programs that have comprehensive sex education components generally have lower rates of pregnancy than those teenagers who have exposure to abstinence-only programs or no sex education at all.

In many communities, programs that engage youth in community service and/or combine sex education and youth development are also successful in deterring pregnancy. Programs vary in their sites of service from schools, to social agencies, to health clinics, to youth organizations, to churches. Other countries have taken different approaches. In Sweden, family life and sex education have been taught in schools since the 1950s, and since 1975, abortion has been free on demand. Contraceptive counseling is free and readily available at family planning and youth health clinics along with STI screening.

Secondary prevention programs are fewer in number. In the USA, some communities have tried to “pay” young mothers to not become pregnant again, but these efforts have not always been fruitful. Home visiting by nurses has been successful in some areas, and many communities have developed “Teen Tot” Clinics that provide a “one-stop shopping model” for health care for both the teen mother and the baby in the same site at the same time. Both of these latter types of programs have reported some successes.

In the practice setting, the identification of the sexually active adolescent through a confidential clinical interview is a 1st step in pregnancy prevention. The primary care physician should provide the teenager with factual information in a nonjudgmental manner and then guide him or her in the decision-making process of choosing a contraceptive. In addition, the practice setting is an ideal setting to support the teenager who chooses to remain abstinent.