Catherine Stevens-Simon

A village would be nice but …: It takes a long-acting contraceptive to prevent repeat adolescent pregnancies

OBJECTIVE To determine which components of a comprehensive, multidisciplinary, adolescent-oriented maternity program help teenage mothers delay subsequent pregnancies. DESIGN/SETTING/PATIENTS A cohort of 373 participants in a comprehensive, multidisciplinary, adolescent-oriented maternity program was studied. INTERVENTION The program was designed to prevent rapid subsequent pregnancies directly by simplifying access to contraceptives and indirectly by discouraging school drop-out and encouraging the pursuit of careers incompatible with closely spaced childbearing. Parents and children were seen together; nine visits were scheduled during the first postpartum year and four visits during the second year. MAIN OUTCOME MEASURE Repeat adolescent pregnancy. RESULTS The repeat pregnancy rate was 14% at 1 year and 35% at 2 years. Teenage mothers who became pregnant exhibited significantly more repeat pregnancy risk factors but were as compliant with clinic visits as their nonpregnant peers. The contraceptive choices the teenagers made during the puerperium had the most profound effect on their subsequent fertility. A logistic regression analysis identified failure to use Norplant during the puerperium as the strongest predictor of repeat pregnancy during the first 2 postpartum years (relative risk [RR]=8.89; 95% confidence interval [CI]=2.80-28.50). Exhibiting nine or more repeat pregnancy risk factors (RR=2.37; 95% CI=1.38-4.06) and not using Depo-Provera during the puerperium (RR=2.30; 95% CI=1.60-3.29) also predicted repeat conception, but clinic visits and return to school postpartum did not. CONCLUSIONS Using a long-acting hormonal contraceptive during the puerperium was associated with pregnancy prevention during the first 2 postpartum years, but frequent clinic visits, contact with supportive healthcare and social service providers, and return to school were not.

Childhood victimization: relationship to adolescent pregnancy outcome

Childhood sexual abuse is a common antecedents of adolescent pregnancy. We studied the pregnancies of 127 poor, black, 12- to 18-year-olds; 42 (33%) of whom reported that they had been physically or sexually abused prior to conception. We hypothesized that during pregnancy: (a) Previously abused adolescents report more stress and depression and less adequate social support than do nonabused adolescents; and (b) Previously abused adolescents obtain less prenatal care, gain less weight, engage in more substance abuse, and give birth to smaller babies than do nonabused adolescents. Consistent with the first study hypothesis, we found that abused adolescents scored significantly higher on stress and depression scales and rated their families as less supportive than did nonabused adolescents. Although there were no group differences in the rate of weight gain or the quantity of prenatal care obtained during pregnancy, abused adolescents were more likely to report substance use during pregnancy and gave birth to significantly smaller, (2,904 +/- 676 vs. 3,198 +/- 443 grams; p = .01), less mature (38.0 +/- 3.4 vs. 39.1 +/- 1.7 weeks; p = .05) infants. Our finding demonstrate the importance of asking pregnant adolescents about abuse.

How Accurately Do Pregnant Adolescents Estimate Their Weight Prior to Pregnancy

An accurate determination of maternal prepregnancy weight (PPW) is critical because it is used to calculate weight gain during pregnancy and is one of the best correlates of infant birthweight. The PPW recorded in the prenatal record is usually obtained as part of the patients history. This study compares PPWs reported by a group of 76 adolescent women (stated weight) with actual weights taken and recorded in medical and school health records by health professionals prior to conception. Simple correlations and a linear regression were used for data analysis. A highly significant correlation (0.98) was found between the stated and actual PPW. Overweight girls tended to underestimate their PPW. These findings suggest that the PPW estimates by adolescents with an identifiable source of medical care are accurate enough to be used to estimate weight gain during pregnancy.

Adolescents at risk for mistreating their children: Part II: a home- and clinic-based prevention program

OBJECTIVE To determine if adding an intensive home visitation component to a comprehensive adolescent-oriented maternity program prevents child abuse and neglect. METHODS We studied 171 participants in a comprehensive, adolescent-oriented maternity program who were deemed to be at high risk for child abuse and neglect. Half were randomly assigned to receive in-home parenting instruction. Major disruptions of primary care-giving by the adolescent mother were classified hierarchically as abuse, neglect, and abandonment. RESULTS Compliance with home visits varied in relation to the support the teenage mothers received from their families and the fathers of their babies (p < .0001). There were no significant treatment group differences in the pattern of health care utilization, the rate of postpartum school return, repeat pregnancies, or child abuse and neglect. The incidence of maltreatment rose in tandem with the predicted risk status of the mother. Ultimately, 19% of the children were removed from their mothers custody. CONCLUSIONS Prediction efforts were effective in identifying at-risk infants, but this intensive home- and clinic-based intervention did not alter the incidence of child maltreatment or maternal life course development. A parenting program that was more inclusive of the support network might be more popular with teenagers and therefore more effective. Our findings also emphasize the importance of including counseling specifically designed to prevent teenagers from abandoning their children.

Are adolescents who report prior sexual abuse at higher risk for pregnancy

Adolescents who report prior sexual abuse are at increased risk for adolescent pregnancy. This may result from earlier, more frequent, less well-protected sexual activity or from a greater desire to conceive. To determine the relative contribution of these two possible explanations to the reported association between sexual abuse and adolescent pregnancy, we studied the reproductive and sexual histories of 200 sexually active 13-18 year old females in relation to self-reported sexual abuse. Anonymous questionnaires revealed that 40 (20%) of the 200 subjects reported sexual abuse. Analyses revealed no group differences in the median age of first voluntary intercourse, the frequency of sexual intercourse, or the consistency of birth control use. Compared to their nonabused peers, however, teenagers reporting abuse were more likely to be trying to conceive (35% vs. 14% p < .01), to have boyfriends pressuring them to conceive (76% vs. 44% p < .01), and to have fears about infertility (38% vs. 16% p < .01). Our findings suggest that childhood sexual abuse may increase the risk of adolescent pregnancy by fostering the desire to conceive. Further study is needed to determine why a disproportionate number of sexually abused adolescents desire pregnancy. The efficacy of adolescent pregnancy prevention programs may be improved by identifying previously abused adolescents and by designing educational interventions that specifically address their desire to conceive.

The Prevalence of Genital Human Papillomavirus Infections in Abused and Nonabused Preadolescent Girls

Objective. To compare the prevalence of genital human papillomavirus (HPV) infections in sexually abused and nonabused preadolescent girls and assess the feasibility of conducting a longitudinal study of the natural history of HPV infection in this population. Method. Consecutively referred, 5- to 12-year-old girls who were evaluated for sexual abuse by a Child Advocacy and Protection Team were invited to participate in the study. During a standard forensic medical examination, 2 specimens for HPV testing were obtained (one by rubbing a Dacron swab over the perineum and the other by lavaging the vagina with phosphate-buffered saline). The specimens were evaluated for HPV DNA by polymerase chain reaction using MY09/11 consensus primers and high-risk (16,18,31,33,35,39,45,51,52, 56,58) and low-risk (6,11,42,43,44) types were detected with a solution hybridization assay, the SHARP Signal System (Digene Diagnostics). The genital area was examined for warts and subclinical, colposcopic evidence of HPV. Participants were invited to return for longitudinal evaluation at 4-month intervals for 2 years. Results. Sexual abuse was confirmed in 29 (72.5%) of the 40 study participants, suspected in 2 (5%), and ruled out in 9 (22.5%). None of the girls had genital warts or abnormal colposcopic findings. HPV DNA was detected in 5 (16%) of the 31 girls with confirmed or suspected sexual abuse (1 with high-risk and 4 with low-risk types) and none of the nonabused girls (Fishers exact test). Girls who tested positive and negative for HPV did not differ significantly in age or type of abuse. Despite close telephone follow-up and numerous attempts to schedule appointments, none of the participants returned for follow-up. Conclusions. Genital HPV infection is more common among sexually abused than nonsexually abused girls, with the majority of infections not clinically apparent. Because it is so difficult to study the natural history of these infections in abused children, it may be necessary to draw inferences about the long-term sequelae of pediatric HPV infections from longitudinal studies of girls who voluntarily initiate sexual activity soon after menarche.

Does incomplete growth and development predispose teenagers to preterm delivery? A template for research

Pregnant teenagers are in better physical condition, suffer from fewer chronic diseases, and engage in fewer health-risky behaviors than socioeconomically similar pregnant adults, but give birth to a disproportionately large number of preterm infants. This systematic review of the adolescent pregnancy literature defines the unique risks associated with being young and pregnant by examining how the physical and psychosocial changes that are characteristic of puberty and adolescence interact with traditional risk factors for preterm delivery. The need for age-specific interventions is discussed and recommendations for future research are made.

RACIAL VARIATION IN VAGINAL PH AMONG HEALTHY SEXUALLY ACTIVE ADOLESCENTS

Background and Objectives: To determine if there are racial differences in vaginal pH that could account for the increased prevalence of trichomoniasis among sexually active black women. Study Design: We measured the pH of vaginal secretions in a group of 273 sexually active, adolescent females without evidence of lower genital tract infection or cervical inflammation. Results: Univariate analyses revealed that seven factors (black race, current alcohol use, nonsmoking status, gravidity, parity, and younger chronologic and gynecologic age) were significantly associated with a more alkaline vaginal pH. After a step-wise multiple regression analysis only three factors (black race, current alcohol use and parity) remained significantly related to vaginal pH, with the strongest association for black race (mean + standard deviation [SD] for vaginal pH among black adolescents 5.3 + 0.7 compared to 4.7 + 0.6 for other adolescents; P < .0001). Conclusion: The pathophysiologic mechanisms that underlie the racial differences we identified in vaginal pH remain to be elucidated. Nevertheless, we speculate that race-related variations in the pH of normal vaginal secretions may decrease the resistance of black adolescents, one of the highest-risk obstetric population in this country, to common vaginal infections, such as trichomoniasis and bacterial vaginosis.

Reasons For First Teen Pregnancies Predict the Rate of Subsequent Teen Conceptions

Objective. To identify reasons for inconsistent contraceptive use that antedate conception and continue to predispose participants in adolescent-oriented maternity programs to unsafe sexual practices after delivery. We hypothesized that teens who attributed their failure to use contraceptives before their first conception exclusively to concerns about their side effects and/or their own lack of motivation to prevent conception would report less consistent contraceptive use and more repeat conceptions than would teens who attributed their previous failure to use contraceptives to their lack of capacity to do so. Method. We conducted a 2-year, prospective, longitudinal study of contraceptive use and repeat conceptions in a racially/ethnically diverse population of poor 13- to 18-year-olds. The 198 study participants were enrolled consecutively during their first pregnancies from an adolescent-oriented maternity program. Results. The majority (84%) of the teens attributed their failure to use contraceptives before their first pregnancy partially to a lack of capacity to do so. As hypothesized, these teen mothers were significantly more likely to use hormonal contraceptives (85% vs 62%), (particularly Norplant, 47% vs 19%) and less likely to conceive again (13% vs 41%). Most teens attributed their inconsistent contraceptive use during the postpartum study period to three factors: side effects, plans to abstain from sexual intercourse, and their lack of motivation to postpone additional childbearing. Conclusions. The reasons teen mothers give for not using contraceptives consistently before their first pregnancies predict the occurrence of subsequent conceptions during adolescence. Those who attribute their previous failure to use contraceptives consistently to side-effect concerns and their own lack of motivation to postpone childbearing are least likely to use hormonal contraceptives after delivery and most likely to conceive again. Our findings suggest that future research should focus on the development of more effective interventions for preventing repeat conceptions among adolescent mothers who had the capacity to prevent their first pregnancies.

What is the relationship between postpartum withdrawal from school and repeat pregnancy among adolescent mothers

An association between the failure of teenage mothers to return to school postpartum and rapid repeat pregnancy (recidivism) has been described. We report the postpartum education pursuits and contraceptive practices of 29 teenage mothers. Our data, together with the literature, suggest that with close postpartum follow-up, young mothers who are not motivated to return to school following delivery can effectively postpone pregnancy.