Margo DeVoe

Home visiting for adolescent mothers: Effects on parenting, maternal life course, and primary care linkage

PURPOSE Adolescent mothers are at risk for rapidly becoming pregnant again and for depression, school dropout, and poor parenting. We evaluated the impact of a community-based home-visiting program on these outcomes and on linking the adolescents with primary care. METHODS Pregnant adolescents aged 12 to 18 years, predominantly with low incomes and of African American race, were recruited from urban prenatal care sites and randomly assigned to home visiting or usual care. Trained home visitors, recruited from local communities, were paired with each adolescent and provided services through the child’s second birthday. They delivered a parenting curriculum, encouraged contraceptive use, connected the teen with primary care, and promoted school continuation. Research assistants collected data via structured interviews at baseline and at 1 and 2 years of follow-up using validated instruments to measure parenting (Adult-Adolescent Parenting Inventory) and depression (Center for Epidemiologic Studies Depression). School status and repeat pregnancy were self-reported. We measured program impact over time with intention-to-treat analyses using generalized estimating equations (GEE). RESULTS Of 122 eligible pregnant adolescents, 84 consented, completed baseline assessments, and were randomized to a home-visited group (n = 44) or a control group (n = 40). Eighty-three percent completed year 1 or year 2 follow-up assessments, or both. With GEE, controlling for baseline differences, follow-up parenting scores for home-visited teens were 5.5 points higher than those for control teens (95% confidence interval, 0.5–10.4 points; P = .03) and their adjusted odds of school continuation were 3.5 times greater (95% confidence interval, 1.1–11.8; P <.05). The program did not have any impact on repeat pregnancy, depression, or linkage with primary care. CONCLUSIONS This community-based home-visiting program improved adolescent mothers’ parenting attitudes and school continuation, but it did not reduce their odds of repeat pregnancy or depression or achieve coordination with primary care. Coordinated care may require explicit mechanisms to promote communication between the community program and primary care.

Motivational intervention to reduce rapid subsequent births to adolescent mothers: a community-based randomized trial.

PURPOSE One-quarter of adolescent mothers bear another child within 2 years, compounding their risk of poorer medical, educational, economic, and parenting outcomes. Most efforts to prevent rapid subsequent birth to teenagers have been unsuccessful but have seldom addressed motivational processes. METHODS We conducted a randomized trial to determine the effectiveness of a computer-assisted motivational intervention (CAMI) in preventing rapid subsequent birth to adolescent mothers. Pregnant teenagers (N = 235), aged 18 years and older who were at more than 24 weeks’ gestation, were recruited from urban prenatal clinics serving low-income, predominantly African American communities. After completing baseline assessments, they were randomly assigned to 3 groups: (1) those in CAMI plus enhanced home visit (n = 80) received a multi-component home-based intervention (CAMI+); (2) those in CAMI−only (n = 87) received a single component home-based intervention; (3) and those in usual-care control (n = 68) received standard usual care. Teens in both intervention groups received CAMI sessions at quarterly intervals until 2 years’ postpartum. Those in the CAMI+ group also received monthly home visits with parenting education and support. CAMI algorithms, based on the transtheoretical model, assessed sexual relationships and contraception-use intentions and behaviors, and readiness to engage in pregnancy prevention. Trained interventionists used CAMI risk summaries to guide motivational interviewing. Repeat birth by 24 months’ postpartum was measured with birth certificates. RESULTS Intent-to-treat analysis indicated that the CAMI+ group compared with the usual-care control group exhibited a trend toward lower birth rates (13.8% vs 25.0%; P = .08), whereas the CAMI-only group did not (17.2% vs 25.0%; P = .32). Controlling for baseline group differences, the hazard ratio (HR) for repeat birth was significantly lower for the CAMI+ group than it was with the usual-care group (HR = 0.45; 95% CI, 0.21–0.98). We developed complier average causal effects models to produce unbiased estimates of intervention effects accounting for variable participation. Completing 2 or more CAMI sessions significantly reduced the risk of repeat birth in both groups: CAMI+ (HR = 0.40; 95% CI, 0.16–0.98) and CAMI−only (HR = 0.19; 95% CI, 0.05–0.69). CONCLUSIONS Receipt of 2 or more CAMI sessions, either alone or within a multicomponent home-based intervention, reduced the risk of rapid subsequent birth to adolescent mothers.

Double jeopardy: depressive symptoms and rapid subsequent pregnancy in adolescent mothers.

OBJECTIVE To examine whether depressive symptoms are a risk factor for a subsequent pregnancy in adolescent mothers. DESIGN Secondary analysis from a longitudinal risk-reduction intervention. SETTING Five community-based prenatal sites in Baltimore, Maryland. PARTICIPANTS Two hundred sixty-nine consenting teens, predominantly African American and with low income, who received prenatal care at any of the 5 community-based prenatal sites and completed follow-up questionnaires at 1 or 2 years post partum. Intervention Baseline depressive symptoms were measured with the Center for Epidemiological Studies Depression Scale. Outcome Measure Occurrence of and time to subsequent pregnancy by 2 years post partum. RESULTS Among teens completing at least 1 follow-up questionnaire, baseline depressive symptoms were present in 46%. A subsequent pregnancy by 2 years post partum was experienced by 49%, with a mean (SD) time to first subsequent pregnancy of 11.4 (5.8) months. Depressive symptoms were associated with increased risk of subsequent pregnancy in both unadjusted models (hazard ratio, 1.44; 95% confidence interval, 1.01-2.03) and adjusted models (hazard ratio, 1.44; 95% confidence interval, 1.00-2.01). CONCLUSIONS Depressive symptoms may be an independent risk factor for subsequent pregnancy in African American adolescent mothers. Because depression is treatable, future studies should evaluate whether improved recognition and treatment of adolescent depression reduces the risk of rapid subsequent pregnancy.

Reduced low birth weight for teenagers receiving prenatal care at a school-based health center: effect of access and comprehensive care

PURPOSE To examine and compare access to care, comprehensiveness of care, and birth outcomes for teenagers receiving prenatal care in comprehensive adolescent pregnancy programs (CAPPS) in two different settings: school-based vs. hospital-based. METHODS Retrospective sohort study using existing data sources: medical records and birth certificates. Using school rosters and hospital clinic databases, we identified pregnant adolescents < or =18 years old who delivered a baby between July 1, 1995 and August 30, 1997 and who received prenatal care in a school-based CAPP (SB-CAPP) or hospital-based CAPP (HB-CAPP). Process of care measures (prenatal care adequacy and comprehensive care) and outcomes (low birth weight) were examined by site of care. Logistic regression models were computed to predict the odds of low birth weight by site of prenatal care, adjusting for prenatal care adequacy, comprehensive care, and possible confounders including baseline maternal characteristics. RESULTS Three-hundred-ninety eligible teens were identified. Mean age was 15.9 years, 93% were African-American, 84% in school, 13% had a prior birth, and 11% were cigarette smokers. Teens receiving care in the SB-CAPP were significantly younger and more likely to be in school than those in the HB-CAPP. Overall, the two groups had similar low rates of prenatal care adequacy, but compared with teens in the SB-CAPP, those in the HB-CAPP were 1.5 times less likely to receive comprehensive care. Logistic regression analyses adjusting for baseline maternal differences showed that HB-CAPP teens were more than three times as likely to deliver a low birth weight infant compared with SB-CAPP teens (AOR 3.75; 95% CI 1.05-13.36). The increased odds of low birth weight for HB-CAPP teens attenuated when prenatal care was adequate and comprehensive (AOR-HB-CAPP: 2.31, 95% CI 0.65-8.24). CONCLUSIONS School-based prenatal care was associated with significantly lower odds of low birth weight compared with HB-CAPP care. Although selection bias may be a factor in this observational study, our findings suggest that these improved birth outcomes may be mediated through prenatal care adequacy and provision of comprehensive care.

Cost-effectiveness of a Motivational Intervention to Reduce Rapid Repeated Childbearing in High-Risk Adolescent Mothers A Rebirth of Economic and Policy Considerations

OBJECTIVE To determine the cost-effectiveness of an intervention that successfully reduced rapid repeated births within 2 years of an index birth to adolescent mothers. DESIGN Randomized, controlled trial conducted from February 2003 to October 2007. SETTING Home-based intervention with participants recruited from 5 urban clinics that provide care to low-income African American communities. PARTICIPANTS Two hundred thirty-five pregnant teenagers (n = 235) aged 18 years or younger who were at 24 or more weeks of gestation at recruitment were followed up for 27 months. INTERVENTIONS Participants were randomly assigned to usual care (n = 68) or 1 of 2 home-based interventions conducted by community outreach workers: (1) computer-assisted motivational intervention (CAMI) conducted quarterly with additional visits (CAMI+ [n = 80]) or (2) CAMI only (n = 87), a single-component motivational intervention conducted quarterly. MAIN OUTCOMES Additional births by 24 months post partum determined from birth certificates, total and weighted mean intervention costs, cost per participant, and incremental cost-effectiveness ratios, defined as cost per prevented repeated birth. RESULTS Relative to usual care, CAMI significantly reduced repeated births (adjusted odds ratio, 0.47; 95% confidence interval, 0.22-0.97). Mean intervention costs per adolescent were

Double Jeopardy : Depressive Symptoms and Rapid Subsequent Pregnancy in Adolescent Mothers

2064, with incremental cost-effectiveness ratios per prevented repeated birth of

Emergency department use by pregnant adolescents

21 895 (unadjusted),

Reduced School Dropout Rates Among Adolescent Mothers Receiving School-Based Prenatal Care

17 388 (adjusted), and

The Effect of Volunteer Home Visitation for Adolescent Mothers on Parenting and Mental Health Outcomes: A Randomized Trial

13 687 for a high-risk subgroup termed newly insured (eligible for but not enrolled in public insurance). CONCLUSIONS The CAMI costs and cost-effectiveness compare favorably with other effective programs aimed at preventing repeated teenage births. Replication of these results in broader samples of adolescents would provide policy guidance for what works, for whom, and at what cost.

The Effect of Volunteer Home Visitation for Adolescent Mothers on Parenting and Mental Health Outcomes

Adolescent mothers in the United States are twice as likely as adults to become depressed, and African Americans seem to be especially at risk. A recent meta-analysis showed that nearly 1 in 5 teen mothers had another pregnancy within 12 months, and nearly 40% within 2 years. Both rapid subsequent pregnancy and maternal depression are associated with an increased risk of child abuse and neglect, as well as impaired intellectual development and psychosocial functioning. This study evaluated depressive symptoms using the Center for Epidemiological Studies Depression Scale in 269 pregnant teenagers age 12-18 years who were seen at 5 community-based prenatal sites. The subjects-predominantly low-income African Americans-were interviewed 1 and 2 years after delivery. Nearly half of the 245 teens followed until 2 years postpartum had at least one subsequent pregnancy, and 10% had more than one. One-third of 24 participants had another pregnancy within 12 months. The mean interval between the index birth and first subsequent pregnancy was 11.4 months. The teens who had a subsequent pregnancy were more likely to have dropped out of school, to not use condoms consistently, and to claim a relationship with their infants father. Subsequent pregnancies were significantly more frequent in teens having depressive symptoms at baseline, even after adjusting for numerous possible confounding factors. In addition, teens with depressive symptoms tended to have a subsequent pregnancy significantly sooner after the index birth compared to those without such symptoms. These findings suggest that, in teenage mothers, depression may be an important and independent risk factor for a subsequent pregnancy within 1 to 2 years of an index pregnancy. Because depression is treatable, it will be of interest to learn whether better recognition will lessen the risk of a rapid subsequent pregnancy.