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Adolescent Pregnancy: Can We Solve the Problem?

1990; Elsevier BV; Volume: 65; Issue: 8 Linguagem: Inglês

10.1016/s0025-6196(12)62729-3

1942-5546

John T. Repke,

Amoebic Infections and Treatments

In this issue of the Proceedings (pages 1061 to 1066), Van Winter and Simmons address the problem of adolescent pregnancy with the concept of comprehensive care. Although this is not a new approach, the proposal deserves attention. The management of adolescent pregnancy is an important issue not only to the individual woman but also to society in general because of the magnitude of this problem in the United States. The Alan Guttmacher Institute1Jones EF Forrest JD Goldman N Henshaw SK Lincoln R Rosoff JI Westoff CF Wulf D Teenage pregnancy in developed countries: determinants and policy implications.Farn Plann Perspec. 1985; 17: 53-63Crossref PubMed Scopus (268) Google Scholar places teenage pregnancy rates in the United States at the highest level among western nations–96 per 1,000 for women between the ages of 15 and 19 years. The reasons for this high rate are not entirely known; however, some proposed explanations include lack of knowledge about contraceptives and cultural differences that may promote teenage motherhood as a desirable goal. Other reasons for our high rate of teenage pregnancy are listed in Table 1.Table 1Factors Involved in Adolescent Pregnancy InsecurityDependency needsResponse to stressAttempt to gain respectImpulsivityAttempt to replace a lossFeelings of invulnerability Open table in a new tab As with all public health issues, primary prevention is the most desirable goal. Community-and school-based clinics are one approach to primary prevention, but such clinics have not always been welcomed by administrators, especially if the focus was on human reproduction and issues related to sexual behavior. In fact, our society's unwillingness to face these issues has necessitated such measures as changing curricular titles from “sex education” to “family life education.” This unwillingness to confront these issues is also partially responsible for our failure, thus far, to reduce adolescent pregnancy rates. Consequently, the issue has become a challenge of how best to deal with the adolescent girl who has become pregnant. The comprehensive approach to obstetric care, as proposed by Van Winter and Simmons, seems to be the best model for managing the pregnant adolescent. One of the first of these types of programs was developed at The Johns Hopkins Hospital by Dr. Janet Hardy and Dr. Theodore King and formally instituted in 1973. The effectiveness of the comprehensive approach has been well substantiated.2Repke JT Medical management of pregnant adolescents.Md Med J. 1987; 36: 932-934PubMed Google Scholar, 3Hardy JB King TM Repke JT The Johns Hopkins Adolescent Pregnancy Program: an evaluation.Obstet Gynecol. 1987; 69: 300-306PubMed Google Scholar, 4Repke JT An ongoing program with a special approach.Contemp Obstet Gynecol. 1989; 34: 117-124Google Scholar One of the important aspects of a comprehensive approach is inclusion of social service programs in combination with continuity of medical care. The cost to society has also been staggering (Table 2, Table 3). These expenses extend beyond simple prenatal care and include other societal investments relative to the mother and the infant.Table 2Sexual Activity and Births Among Unmarried Adolescents (15 to 19 Years Old) in the United StatesAdolescents (%)YearsSexually activeBirths1970–197227.6301979–198046.0481984–198542.057 Open table in a new tab Table 3Abortions Among Adolescents in the United StatesAge (yr)Pregnancies ending in abortion (%)*In the United States, 13% of pregnancies end in miscarriage, and 30% of all abortions are performed on teens.<145015–174018–1937* In the United States, 13% of pregnancies end in miscarriage, and 30% of all abortions are performed on teens. Open table in a new tab Adolescents who become pregnant frequently drop out of school.5US Department of Education High School Dropouts: Descriptive Information From High School and Beyond. Publication No. NCES 83-221b. US Government Printing Office, Washington, DC1983Google Scholar In fact, more than two-thirds of the adolescents who have their first child before age 15 years, and more than half of those whose first birth is between ages 15 and 17 years, do not complete high school.6Southern Regional Project on Infant Mortality Adolescent Childbearing in the South. Georgia Department of Human Resources, AtlantaApril 1988Google Scholar Completing this circle is the fact that teens with below-average basic learning skills are 5 times more likely to have a child before age 16 years than those with average to above-average skills.7Children's Defense Fund A Call to Action to Make Our Nation Safe for Children: A Briefing Book on the Status of American Children in 1988. Children's Defense Fund, Washington, DC1988Google Scholar Contributing to this educational dilemma is the problem of child care, a service that is essential to the adolescent mother who returns to school but, unfortunately, is unlikely to be readily available. For the women who seek employment, recorded statistics reveal that for each year a first birth is delayed, the annual family income by age 27 years increases by $500. During the course of a lifetime, teenage mothers earn approximately half what their counterparts earn who were not teen mothers.8Hayes CD Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. National Academy Press, Washington, DC1987Google Scholar Two-thirds of the children of teenage mothers are living below the poverty level by the age of 6 years Of those women younger than 30 years of age who receive welfare, 80% had their first child as a teen, and only 16% of single mothers between the ages of 18 and 24 years receive child support. Also, approximately 8% of babies of unmarried teens 15 to 19 years old are placed for adoption each year, and less than 1% of black teens place their babies for adoption.8Hayes CD Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. National Academy Press, Washington, DC1987Google Scholar Other socially relevant issues pertaining to adolescent pregnancy must be considered. The development of parenting skills is extremely important for the proper rearing of a child. Comprehensive adolescent pregnancy programs can play a crucial role in this area. Failure to develop these skills may result in increased child neglect and frank child abuse, perhaps with dire consequences for the next generation.9Widom CS The cycle of violence.Science. 1989; 244: 160-166Crossref PubMed Scopus (1305) Google Scholar In addition to the social service component of comprehensive health care, definite improvements in maternal and infant outcome have been reported with use of this approach. Adolescents have been shown to be at high risk for anemia, preeclampsia, and low-birth-weight babies.3Hardy JB King TM Repke JT The Johns Hopkins Adolescent Pregnancy Program: an evaluation.Obstet Gynecol. 1987; 69: 300-306PubMed Google Scholar They are also at increased risk for sexually transmitted diseases.10Hardy PH Hardy JB Nell EE Graham DA Spence MR Rosenbaum RC Prevalence of six sexually transmitted disease agents among pregnant innercity adolescents and pregnancy outcome.Lancet. 1984; 2: 333-337Abstract PubMed Scopus (206) Google Scholar Although the comprehensive approach may not eliminate adverse outcomes of pregnancy, the incorporation of these concepts facilitates visit compliance. Continuity of health care, primary nursing, health education, social services, and the availability of a registered dietitian all encourage visit compliance. Additionally, such a support mechanism can facilitate utilization of other available support programs, such as WIC (Women, Infants, and Children) or medical-care financial assistance, all of which factors contribute to improved use of health-care services. The experience at Johns Hopkins supports the soundness, practicality, and potential success of the approach proposed by Van Winter and Simmons. In an age of increasing “frugality” at federal, state, and local levels, we must not cut costs at the expense of an entire generation. An abundance of published data confirms the statistic that for every dollar spent on prenatal care, $3 are saved on managing what would be the consequences of the lack ofthat care.11Nagey DA The content of prenatal care.Obstet Gynecol. 1989; 74: 516-528PubMed Google Scholar The unique feature of the comprehensive approach to adolescent pregnancy is that it goes beyond simply the successful negotiation of the gestational period. It deals with life-style issues such as nutrition, drug and alcohol use, and smoking as well as issues relating to parenting and returning to society as a productive person. Preventing repeat pregnancies, returning to school, and caring for the newest family member are also important goals for a comprehensive healthcare program. Obstetricians and pediatricians clearly provide the medical-care foundation, but the other components of this type of approach are of equal or greater importance. Therefore, we must not be myopic in our proposals for the management of adolescent pregnancies. The fruits of comprehensive programs will be borne as we enter the next century. Until then, support from the government and private foundations must sustain those programs that provide the only hope for the next generation.