REVIEW URRENT C OPINION
Teen pregnancy: an update Katherine A. McCracken and Meredith Loveless
Purpose of review To provide clinicians with a review of recent research and clinically applicable tools regarding teen pregnancy. Recent findings Teen pregnancy rates have declined but still remain a significant problem in the USA. Teen pregnancy prevention was identified by Centers for Disease Control and Prevention as one of its top six priorities, which is increasing research and intervention data. Long-acting contraceptive methods are acceptable to teens and have been shown to reduce teen birth rates. Pregnant teens need special attention to counseling on pregnancy options and reducing risk during pregnancy with regular prenatal care. Postpartum teens should be encouraged and supported to breastfeed, monitored for depression, and have access to reliable contraception to avoid repeat undesired pregnancy. Summary This review highlights important issues for all providers caring for female adolescents and those who may encounter teen pregnancy. Foremost prevention of teen pregnancy by comprehensive sexual education and access to contraception is the priority. Educating patients and healthcare providers about safety and efficacy of long-acting reversible contraception is a good step to reducing undesired teen pregnancies. Rates of postpartum depression are greater in adolescents than in adults, and adolescent mothers need to be screened and monitored for depression. Strategies to avoid another undesired pregnancy shortly after delivery should be implemented. Keywords long-acting contraception, postpartum depression, teen births, teen pregnancy
INTRODUCTION Teen pregnancy and childbearing have significant social and economic impacts for the adolescents involved, their children, their communities, and society as a whole. The effect on educational attainment is significant, with only 40% of teen mothers graduating from high school, and less than 2% of those who have had a baby before age 18 finishing college by age 30 [1]. Furthermore, children of adolescent mothers have higher rates of abuse and neglect, are more likely to become teen mothers themselves, and more likely to be incarcerated [2 ]. Unfortunately, despite recent decreases in teen birth rates, the USA continues to have higher teen pregnancy, birth, sexually transmitted disease, and abortion rates, when compared with other Western industrialized nations [3]. Furthermore, there continues to be considerable racial disparities for both teen pregnancy and birth rates; non-Hispanic black youth, Hispanic/Latino youth, American Indian/ Alaskan Native youth, and socioeconomically disadvantaged youth of any race continue to have the highest rates of teen pregnancy and childbirth. &&
Low socioeconomic status, underemployment, low income, low education levels, neighborhood disadvantage, neighborhood physical disorder, and neighborhood-level income inequality all contribute to increased rates of teen pregnancy [4]. According to data from the National Vital Statistics Reports, the overall live birth rate in 2012 dropped to 29.4 per 1000 women aged 15–19. This fell in line with the ongoing decline beginning after 1991 – at which time the teen birth rate was 84.1 per 1000. In 2012, approximately 305 000 babies were born to teens aged 15–19 [5 ]. It is important to note, that the data presented for 2012 are examining only teen birth rates, which is not synonymous with the teen pregnancy rate. Data on the teen pregnancy rate, &
Kosair Children’s Hospital, Louisville, Kentucky, USA Correspondence to Meredith Loveless, MD, Kosair Children’s Hospital, Gynecology Specialists, 210 E. Gray Street, Suite 600, Louisville, KY 40202, USA. Tel: +1 502 6293730; fax: +1 502 6293734; e-mail: [email protected] Curr Opin Obstet Gynecol 2014, 26:355–359 DOI:10.1097/GCO.0000000000000102
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KEY POINTS Teen pregnancy rates have declined, but still remain a significant problem in the USA. There continue to be considerable racial disparities for both teen pregnancy and birth rates. Long-acting contraceptive methods, such as the intrauterine device and contraceptive implant, are well tolerated and acceptable to teens and have been shown to reduce teen birth rates. Postpartum teens should be encouraged and supported to breastfeed, monitored for depression, and given access to reliable contraception to avoid repeat undesired pregnancy.
which includes miscarriages, stillbirths, and abortions, are not yet available for 2012. Of particular concern are births to younger teens aged 15–17 years. In 2012, there were 86 423 births to teens in this age group, accounting for 28% of all births to teens aged 15–19 years. This is a decline from 36% in 1991 [6]. Childbearing in this age group may have even more of an detrimental social and economic impact; as those aged 15–17 years were less likely to earn a high school diploma or general equivalency degree, compared to older teens who gave birth [7]. It is concerning that although 91% of female teens aged 15–17 years had received formal sex education on contraceptive methods and abstinence, 83% reported having received no formal sex education prior to first sex [8]. There is clearly room for improvement in how we as a nation deliver comprehensive sex education. It is encouraging that among sexually active female teens aged 15–17, 92% used a contraceptive method at last intercourse according to data from the National Survey of Family Growth from 2006 to 2010. However, despite recent campaigns highlighting the safety and effectiveness of long-acting reversible contraceptive (LARC) methods, only 4.5% of teens used such methods at last intercourse [9]. In this review, we will highlight recent advances in the field of teen pregnancy within the past 12 months. It is our hope that this will provide clinicians with a review of recent research and clinically applicable tools regarding teen pregnancy.
TEEN PREGNANCY PREVENTION Research on ways to reduce teen pregnancy is high priority. The Centers for Disease Control and Prevention has identified teen pregnancy prevention as one of its six top priorities. The National Campaign to Prevent Teen and Unplanned Pregnancy is an 356
www.co-obgyn.com
example of an evidence-based nonprofit organization that advocates to reduce teen pregnancy by focusing on comprehensive sexual education and contraception options counseling, providing youthfriendly clinical services, implementing communitywide programs, and providing national support for programs that focus on decreasing racial/ethnic and geographical disparities in teen pregnancy rates [10]. One strategy that is making great strides in reducing teen pregnancy is the increased use of LARC methods among adolescents. LARC methods include intrauterine devices (IUDs) and the etonogestrel implant and are the most effective methods to prevent pregnancy, with typical-use effectiveness rates of greater than 99%, and 1-year continuation rates of 80–90% [11]. The American Congress of Obstetricians and Gynecologists recommends LARC be offered as first-line contraceptive options for all adolescents [12]. Results from the Contraceptive CHOICE Project (CHOICE), an ongoing prospective cohort study of 9256 women in the St. Louis region, demonstrated that removing cost barriers and providing a scripted introduction to LARC methods increases use among women – including adolescents [13]. Seventy-five percent of all participants chose a LARC method at enrollment. The CHOICE cohort included 2031 women aged 14–20 years; 62% chose LARC methods – 39% chose the IUD and 23% chose the implant [14]. This study showed failure rates for adolescents using oral contraceptives, the vaginal ring, or transdermal patch to be twice as high as failure rates in older women. Additionally, the study showed LARC methods to have failure rates that were approximately 22 times lower than those of non-LARC methods [15]. The teen pregnancy data from the CHOICE project was exciting; among teen participants, the birth rate was 6.3 per 1000 teens, which is significantly lower than the national rate [16]. Jaccard and Levitz provide a framework for adolescent contraceptive counseling that focuses on confidentiality, adolescent development, and practical principles to incorporate into method counseling. They pay particular attention to method choice, correct and consistent use, giving priority to the most effective methods, addressing how methods fit an adolescent’s lifestyle, sideeffects, and using quick-start options when medically appropriate [17].
PRENATAL CARE Given the high teen pregnancy and birth rates in the USA, it is likely that all clinicians who care for Volume 26 Number 5 October 2014
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Teen pregnancy: an update McCracken and Loveless
adolescents will encounter a pregnant teen. For the majority of pregnant adolescents, pregnancy was an unplanned event. A diagnosis of pregnancy and the decision-making period shortly thereafter can be a time of great turmoil in the adolescent’s life. It is crucial that pregnant adolescents are ‘given complete information on all available options’ [18] – however, this counseling may vary widely. Dobkin et al. [19 ] provides a framework for pregnancy options counseling for adolescents. They suggest that options counseling should follow a shared decision-making framework, during which adolescents receive comprehensive information about options when using a supportive, neutral approach that helps identify the option that is most appropriate for the individual. This also involves the clinician familiarizing him or herself with the legal statutes of their state regarding minors and parental notification/consent and the availability of adoption and termination services. Assessment of gestational age is important to determine options available to them. Close-interval follow-up is established regardless of the decision the patient makes. Lastly, establishing a plan for post-termination or postpartum contraception is extremely important. For the adolescent who decides to continue their pregnancy, prenatal care does not entirely differ from that of adult women. However, adolescents do have higher rates of poor birth outcomes such as preterm birth and low birth weight infants, compared to adult women. This seems to be related to inadequate prenatal care, nutritional deficiencies, and poverty. Therefore, clinicians should stay attuned for signs and symptoms of preterm parturition and fetal growth that does not follow expected growth curves. Adolescent pregnancy care should pay particular attention to counseling on domestic violence, tobacco use, substance abuse, nutrition, and depression. Teens may also require additional assistance navigating the healthcare system and securing resources from social assistance programs. &
POSTPARTUM CONSIDERATIONS As with patients of all ages, postpartum care is an important component of comprehensive pregnancy care. There are three areas of postpartum care that require particular attention for adolescent patients: breastfeeding, depression, and repeat pregnancy.
documented, and organizations such as the WHO, the American Academy of Pediatrics, the American Congress of Obstetrics and Gynecology, and the US Preventive Services Task Force advise mothers to breastfeed infants for the first 6 months of life. However, adolescent mothers are less likely to breastfeed than older mothers. This is unfortunate, as adolescents themselves may benefit from breastfeeding. It is cost-effective, may result in increased inter-pregnancy intervals, and may foster motherinfant bonding. A longitudinal cohort of adolescent females (aged 14–21 years) and their male partners were observed from pregnancy through 6 months postpartum [20]. This study found that adolescents who initiated breastfeeding were more likely to have intended to breastfeed, to have partners who wanted them to breastfeed, and who had complications during labor and delivery. Interesting, greater social support was associated with significantly lower odds of breastfeeding. The unexpected finding of decreased breastfeeding initiation in adolescents with increased social support may indicate that increased support has the potential to interfere with the adolescent’s status as the infant’s primary caregiver. When examining the duration of breastfeeding, the majority of adolescents who initiated breastfeeding had stopped by 6 months – with the average duration of breastfeeding less than 6 weeks. Breastfeeding difficulty, obesity, and receiving women, infants, and children public assistance were associated with lower odds of exclusive breastfeeding. A retrospective population-based cohort study in Ohio confirmed that adolescent mothers (aged 20 years) [21]. Indicators of social support and socioeconomic stability were the most influential factors on lack of breastfeeding initiation; decreased rates were associated with being unmarried and having Medicaid as the primary insurance provider. Rates were also lower among adolescent mothers with premature births, which is concerning, given that premature infants may glean the largest benefit from breast milk. Inventions targeting breastfeeding initiation should target both the adolescent mother and their support systems. Future programs should also assess the complex dynamics of adolescent relationships and ongoing outpatient support networks.
Depression Breastfeeding The health, developmental, and psychosocial benefits of breastfeeding for the infant are well
Depression screening is a routine part of postpartum care for all women. It is especially important in the care of adolescent mothers, as the prevalence of
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postpartum depression among adolescent mothers is significantly higher compared to adult postpartum women. Postpartum depression affects both the mother and her developing infant. In a study of 180 adolescent African-American and Latino/Hispanic mothers, Huang et al. [22] found that higher levels of maternal depression are associated with greater developmental delays in infants at 18 months of age. Higher levels of parenting stress and less perceived social support were also associated with higher levels of depression at baseline in adolescent mothers. Clinicians who care for adolescent mothers and their children should make it a priority to implement screening into their patient care algorithms. A study by Venkatesh et al. [23 ] documented ways to easily screen for postpartum depression using variations of the Edinburgh Postnatal Depression Scale (EPDS). They found that the original 10-item EPDS, as well as two subscales (the EPDS-7, which focuses on depression symptoms, and the EPDS-2, which focuses on depressed mood and anhedonia) are accurate screening tools. These brief scales can be implemented into a busy clinical practice to help identify adolescent mothers with postpartum depression. &
Prevention of rapid repeat pregnancy and birth Adequate time between births lowers the risk of preterm births, low birth weight infants, and small for gestational age infants [24]. Rapid repeat births (defined as a pregnancy within 2 years of previous pregnancy) may pose even greater challenges to adolescent mothers than to their adult counterparts, as it becomes more difficult to attend school and pursue job opportunities with more than one teen pregnancy. Approximately 35% of recently pregnant adolescents have experienced a rapid repeat pregnancy; and two-thirds of these pregnancies were unintended [25 ]. It is troubling that nearly one in five teen births in 2010 was a repeat birth (defined as having two or more pregnancies resulting in a live birth before age 20) [26]. The prevalence of repeat teen births has decreased, from 19.5% in 2007 to 18.3% in 2010. However, racial/ethnic disparities persist with American Indian/Alaskan natives, Hispanics, non-Hispanic blacks experiencing the highest rates of repeat teen births. According to the Pregnancy Risk Assessment Monitoring System [27], which collects state-specific, population-based data on maternal attitudes and experiences before, during, and after pregnancy, 90.7% of adolescent mothers were &
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sexually active, 8% were not sexually active, and 1.3% were pregnant. Among those who were sexually active, approximately 76% used contraceptives and were more likely to use LARC methods than all sexually active teens (21.5 versus 4.5%). Adolescent mothers who were sexually active but not using contraception cited reasons for nonuse that included not wanting to use birth control, partner objections, inability to pay for birth control, and wanting to get pregnant. In a study of postpartum adolescents in seven states, using Pregnancy Risk Assessment Monitoring data, Wilson et al. [28] found that prenatal contraceptive counseling and attending a postpartum clinic visit were associated with a reduction in unprotected sex. Moreover, adolescents who attended a postpartum visit were more likely to report using hormonal contraception. In this cohort, 12% used LARC methods (11% used IUDs and 1% used implants). However, 14% of adolescent mothers did not return for a postpartum visit. The relatively high risk of losing an adolescent to follow-up after a delivery or abortion underscores the need to eliminate barriers to immediate LARC placement after a delivery or abortion. The optimal time of placement depends on several factors. While there is limited information regarding placement of an IUD immediately following delivery until about 4–6 weeks postpartum, the Centers for Disease Control and Prevention medical eligibility criteria categorizes IUD placement before 4 weeks postpartum as category 2 (benefits generally outweigh risks) [29]. Although there may be a slightly increased risk of IUD expulsion [30], continuation rates are higher in those who receive immediate placement [31–34]. Furthermore, the subdermal implant can be placed immediately following a delivery or abortion without any adverse effects on lactation or infant growth [35]. Baldwin and Edelman, in their review of the effect of LARC on rapid repeat pregnancy in adolescents, stress that adolescents should receive individualized, noncoercive counseling should begin during the prenatal period, and should lead to the opportunity to receive LARC methods immediately following delivery or abortion, or prior to discharge from the hospital. Those who intend to use LARC, but have a gap between the request and receipt of such a method, should be provided with non-LARC methods in the interim [36].
CONCLUSION Teen pregnancy and childbearing have significant social and economic impacts. Prevention of pregnancy is the first-line approach as most teen Volume 26 Number 5 October 2014
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Teen pregnancy: an update McCracken and Loveless
pregnancies are unplanned. Comprehensive sex education and counseling on contraception focused on increasing the use of LARC options are necessary to achieve this goal. It is encouraging that the prevalence of repeat teen births has decreased; however, significant racial/ethnic disparities persist. Teens who are sexually active and not using effective contraception have a very high likelihood of pregnancy within 1 year. Providers should counsel pregnant and parenting adolescents about the importance of adequate birth spacing, encourage the use of the most effective contraceptive methods, and encourage sustained contraceptive use. Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Shuger L. Teen pregnancy and high school dropout: what communities are doing to address these issues. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy and America’s Promise Alliance; 2012. Pregnancy and America’s Promise Alliance; 2012. 2. The National Campaign to Prevent Teen Pregnancy. Why it matters: Teen && pregnancy and overall child well-being. 2007. Washington, DC. United States nonprofit organization provides statistics on adolescent pregnancy, poll results and analyses of factors affecting teenage sexual behavior and sex education. The National Campaign challenges the nation to achieve by the year 2020, a reduction of 20% in the proportion of pregnancies among women under 30 years that are unplanned and a 20% reduction in the teen pregnancy rate. 3. Singh S, Darroch JE. Adolescent pregnancy and childbearing: levels and trends in developed countries. Fam Plann Perspect 2000; 32:14–23. 4. Penman-Aguilar A, Carter M, Snead MC, Kourtis AP. Socioeconomic disadvantage as a social determinant of teen childbearing in the U.S. Public Health Rep 2013; 128 (Suppl 1):5–22. 5. Martin JA, Hamilton BE, Osterman JK, et al. Births: final data for 2012. Natl & Vital Stat Rep 2013; 62:1–20. The report contains the most recent data on teen birth rates. 6. Cox S, Pazol K, Warner L, et al. Vital signs: births to teens aged 15– 17 years–United States, 1991–2012. MMWR Morb Mortal Wkly Rep 2014; 63:312–318. 7. Perper K, Peterson K, Manlove J. Diploma attainment among teen mothers. Fact sheet. Washington, DC: Child Trends; 2010. Available at: http://childtrends.org/wp-content/uploads/2010/01/child_trends-2010_01_22_FS_diplomaattainment.pdf. 8. Lepkowski J, Mosher W, Groves R, et al. Responsive design, weighting, and variance estimation in the 2006–2010 National Survey of Family Growth. Vital Health Stat 2103;2:2–52. 9. Finer JB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States. Fertil Steril 2012; 98:393–397. 10. National Campaign to Prevent Teen and Unplanned Pregnancy. Available at: http://thenationalcampaign.org/. 11. Peipert JM, Zhao Q, Allsworth J, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011; 117:1105–1113.
12. Committee on Adolescent Healthcare Long-Acting Reversible Contraception Working, Group, The American College of Obstetricians and Gynecologists. Committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2012; 120:983– 988. 13. Secura GM, Allsworth JE, Madden T, et al. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. Am J Obstet Gynecol 2010; 203:e1–e7; 115. 14. Mestad R, Secura G, Allsworth JE, et al. Acceptance of long-acting reversible contraceptive methods by adolescent participants in the Contraceptive CHOICE Project. Contraception 2011; 84:493–498. 15. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012; 366:1998–2007. 16. Peipert JF, Madden T, Allsworth JE, et al. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012; 120:1298–1305. 17. Jaccard J, Levitz N. Counseling adolescents about contraception: towards the development of an evidence-based protocol for contraceptive counselors. J Adolesc Health 2013; 52:S6–13. 18. American Academy of Pediatrics Committee on Adolescence. American Academy of Pediatrics Committee on Adolescence: counseling the adolescent about pregnancy options. Pediatrics 1998; 101:938–940. 19. Dobkin LM, Perrucci AC, Dehlendorf C. Pregnancy options counseling for & adolescents: overcoming barriers to care and preserving preference. Curr Probl Pediatr Adolesc Healthcare 2013; 43:96–102. This study describes a model for counseling options for pregnant teens. 20. Sipsma HL, Magriples U, Divney A, et al. Breastfeeding behavior among adolescents: initiation duration, and exclusivity. J Adolesc Health 2013; 53:394–400. 21. Apostolakis-Dyrus K, Valentine C, DeFranco E. Factors associated with breastfeeding initiation in adolescent mothers. J Pediatr 2013; 163:1489–1494. 22. Huang CY, Costeines J, Kaufman JS, et al. Parenting stress, social support, depression for minority adolescent mothers: impact on child development. J Child Fam Stud 2014; 23:255–262. 23. Venkatesh KK, Zlotnick C, Triche EW, et al. Accuracy of brief screening tools & for identifying postpartum depression among adolescent mothers. Pediatrics 2014; 133:e45–53. This study discusses screening tool to use for postpartum depression screening in adolescent mothers. 24. Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA 2006; 295:1809– 1823. 25. Baldwin MK, Edelman AB. The effect of long-acting reversible contraception & on rapid repeat pregnancy in adolescents: a review. J Adolesc Health 2013; 52:S47–52. Article that discusses benefits of LARCs on prevention of rapid repeat pregnancy. 26. Centers for Disease Control and Prevention (CDC). Vital signs: repeat births among teens – United States 2007-2010. MMWR Morb Mortal Wkly Rep 2013; 62:249-255. 27. Centers for Disease Control and Prevention (CDC). Vital signs: repeat births among teens – United States. MMWR Morb Mortal Wkly Rep 2013; 62:249–255. 28. Wilson EK, Fowler CI, Koo HP. Postpartum contraceptive use among adolescent mothers in seven states. J Adolesc Health 2013; 52:278–283. 29. Centers for Disease Control and Prevention (CDC). Update to CDC’s US medical eligibility criteria for contraceptive use 2010: revised recommendations for the use of contraceptive methods during the postpartum period. MMWR Morbid Mortal Wkly Rep 2011; 60:878–883. 30. Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: a systematic review. Contraception 2009; 80:327–336. 31. Chen BA, Reeves MF, Creinin MD, et al. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol 2010; 116:1079–1087. 32. Grimes DA, Lopez LM, Schulz KF, et al. Immediate postpartum insertion of intrauterine devices. Cochrane Database System Rev 2010; CD003036. 33. Levi E, Cantillo E, Ades V, et al. Immediate postplacental IUD insertion at cesarean delivery: a prospective cohort study. Contraception 2012; 86:102– 105. 34. Celen S, Sucak A, Yildiz Y, et al. Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section. Contraception 2011; 84:240–243. 35. Reinprayoon D, Taneepanichskul S, Bunyavejchevin S, et al. Effects of the etonogestrel releasing contraceptive implant (Implanon) on parameters of breastfeeding compared to those of an intrauterine device. Contraception 2000; 62:239–246. 36. Baldwin MK, Edelman AB. The effect of long-acting reversible contraception on rapid repeat pregnancy in adolescents: A review. J Adolesc Health 2013; 52:S47–53.
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Teen pregnancy: an update Katherine A. McCracken and Meredith Loveless
Purpose of review To provide clinicians with a review of recent research and clinically applicable tools regarding teen pregnancy. Recent findings Teen pregnancy rates have declined but still remain a significant problem in the USA. Teen pregnancy prevention was identified by Centers for Disease Control and Prevention as one of its top six priorities, which is increasing research and intervention data. Long-acting contraceptive methods are acceptable to teens and have been shown to reduce teen birth rates. Pregnant teens need special attention to counseling on pregnancy options and reducing risk during pregnancy with regular prenatal care. Postpartum teens should be encouraged and supported to breastfeed, monitored for depression, and have access to reliable contraception to avoid repeat undesired pregnancy. Summary This review highlights important issues for all providers caring for female adolescents and those who may encounter teen pregnancy. Foremost prevention of teen pregnancy by comprehensive sexual education and access to contraception is the priority. Educating patients and healthcare providers about safety and efficacy of long-acting reversible contraception is a good step to reducing undesired teen pregnancies. Rates of postpartum depression are greater in adolescents than in adults, and adolescent mothers need to be screened and monitored for depression. Strategies to avoid another undesired pregnancy shortly after delivery should be implemented. Keywords long-acting contraception, postpartum depression, teen births, teen pregnancy
INTRODUCTION Teen pregnancy and childbearing have significant social and economic impacts for the adolescents involved, their children, their communities, and society as a whole. The effect on educational attainment is significant, with only 40% of teen mothers graduating from high school, and less than 2% of those who have had a baby before age 18 finishing college by age 30 [1]. Furthermore, children of adolescent mothers have higher rates of abuse and neglect, are more likely to become teen mothers themselves, and more likely to be incarcerated [2 ]. Unfortunately, despite recent decreases in teen birth rates, the USA continues to have higher teen pregnancy, birth, sexually transmitted disease, and abortion rates, when compared with other Western industrialized nations [3]. Furthermore, there continues to be considerable racial disparities for both teen pregnancy and birth rates; non-Hispanic black youth, Hispanic/Latino youth, American Indian/ Alaskan Native youth, and socioeconomically disadvantaged youth of any race continue to have the highest rates of teen pregnancy and childbirth. &&
Low socioeconomic status, underemployment, low income, low education levels, neighborhood disadvantage, neighborhood physical disorder, and neighborhood-level income inequality all contribute to increased rates of teen pregnancy [4]. According to data from the National Vital Statistics Reports, the overall live birth rate in 2012 dropped to 29.4 per 1000 women aged 15–19. This fell in line with the ongoing decline beginning after 1991 – at which time the teen birth rate was 84.1 per 1000. In 2012, approximately 305 000 babies were born to teens aged 15–19 [5 ]. It is important to note, that the data presented for 2012 are examining only teen birth rates, which is not synonymous with the teen pregnancy rate. Data on the teen pregnancy rate, &
Kosair Children’s Hospital, Louisville, Kentucky, USA Correspondence to Meredith Loveless, MD, Kosair Children’s Hospital, Gynecology Specialists, 210 E. Gray Street, Suite 600, Louisville, KY 40202, USA. Tel: +1 502 6293730; fax: +1 502 6293734; e-mail: [email protected] Curr Opin Obstet Gynecol 2014, 26:355–359 DOI:10.1097/GCO.0000000000000102
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Adolescent and pediatric gynecology
KEY POINTS Teen pregnancy rates have declined, but still remain a significant problem in the USA. There continue to be considerable racial disparities for both teen pregnancy and birth rates. Long-acting contraceptive methods, such as the intrauterine device and contraceptive implant, are well tolerated and acceptable to teens and have been shown to reduce teen birth rates. Postpartum teens should be encouraged and supported to breastfeed, monitored for depression, and given access to reliable contraception to avoid repeat undesired pregnancy.
which includes miscarriages, stillbirths, and abortions, are not yet available for 2012. Of particular concern are births to younger teens aged 15–17 years. In 2012, there were 86 423 births to teens in this age group, accounting for 28% of all births to teens aged 15–19 years. This is a decline from 36% in 1991 [6]. Childbearing in this age group may have even more of an detrimental social and economic impact; as those aged 15–17 years were less likely to earn a high school diploma or general equivalency degree, compared to older teens who gave birth [7]. It is concerning that although 91% of female teens aged 15–17 years had received formal sex education on contraceptive methods and abstinence, 83% reported having received no formal sex education prior to first sex [8]. There is clearly room for improvement in how we as a nation deliver comprehensive sex education. It is encouraging that among sexually active female teens aged 15–17, 92% used a contraceptive method at last intercourse according to data from the National Survey of Family Growth from 2006 to 2010. However, despite recent campaigns highlighting the safety and effectiveness of long-acting reversible contraceptive (LARC) methods, only 4.5% of teens used such methods at last intercourse [9]. In this review, we will highlight recent advances in the field of teen pregnancy within the past 12 months. It is our hope that this will provide clinicians with a review of recent research and clinically applicable tools regarding teen pregnancy.
TEEN PREGNANCY PREVENTION Research on ways to reduce teen pregnancy is high priority. The Centers for Disease Control and Prevention has identified teen pregnancy prevention as one of its six top priorities. The National Campaign to Prevent Teen and Unplanned Pregnancy is an 356
www.co-obgyn.com
example of an evidence-based nonprofit organization that advocates to reduce teen pregnancy by focusing on comprehensive sexual education and contraception options counseling, providing youthfriendly clinical services, implementing communitywide programs, and providing national support for programs that focus on decreasing racial/ethnic and geographical disparities in teen pregnancy rates [10]. One strategy that is making great strides in reducing teen pregnancy is the increased use of LARC methods among adolescents. LARC methods include intrauterine devices (IUDs) and the etonogestrel implant and are the most effective methods to prevent pregnancy, with typical-use effectiveness rates of greater than 99%, and 1-year continuation rates of 80–90% [11]. The American Congress of Obstetricians and Gynecologists recommends LARC be offered as first-line contraceptive options for all adolescents [12]. Results from the Contraceptive CHOICE Project (CHOICE), an ongoing prospective cohort study of 9256 women in the St. Louis region, demonstrated that removing cost barriers and providing a scripted introduction to LARC methods increases use among women – including adolescents [13]. Seventy-five percent of all participants chose a LARC method at enrollment. The CHOICE cohort included 2031 women aged 14–20 years; 62% chose LARC methods – 39% chose the IUD and 23% chose the implant [14]. This study showed failure rates for adolescents using oral contraceptives, the vaginal ring, or transdermal patch to be twice as high as failure rates in older women. Additionally, the study showed LARC methods to have failure rates that were approximately 22 times lower than those of non-LARC methods [15]. The teen pregnancy data from the CHOICE project was exciting; among teen participants, the birth rate was 6.3 per 1000 teens, which is significantly lower than the national rate [16]. Jaccard and Levitz provide a framework for adolescent contraceptive counseling that focuses on confidentiality, adolescent development, and practical principles to incorporate into method counseling. They pay particular attention to method choice, correct and consistent use, giving priority to the most effective methods, addressing how methods fit an adolescent’s lifestyle, sideeffects, and using quick-start options when medically appropriate [17].
PRENATAL CARE Given the high teen pregnancy and birth rates in the USA, it is likely that all clinicians who care for Volume 26 Number 5 October 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Teen pregnancy: an update McCracken and Loveless
adolescents will encounter a pregnant teen. For the majority of pregnant adolescents, pregnancy was an unplanned event. A diagnosis of pregnancy and the decision-making period shortly thereafter can be a time of great turmoil in the adolescent’s life. It is crucial that pregnant adolescents are ‘given complete information on all available options’ [18] – however, this counseling may vary widely. Dobkin et al. [19 ] provides a framework for pregnancy options counseling for adolescents. They suggest that options counseling should follow a shared decision-making framework, during which adolescents receive comprehensive information about options when using a supportive, neutral approach that helps identify the option that is most appropriate for the individual. This also involves the clinician familiarizing him or herself with the legal statutes of their state regarding minors and parental notification/consent and the availability of adoption and termination services. Assessment of gestational age is important to determine options available to them. Close-interval follow-up is established regardless of the decision the patient makes. Lastly, establishing a plan for post-termination or postpartum contraception is extremely important. For the adolescent who decides to continue their pregnancy, prenatal care does not entirely differ from that of adult women. However, adolescents do have higher rates of poor birth outcomes such as preterm birth and low birth weight infants, compared to adult women. This seems to be related to inadequate prenatal care, nutritional deficiencies, and poverty. Therefore, clinicians should stay attuned for signs and symptoms of preterm parturition and fetal growth that does not follow expected growth curves. Adolescent pregnancy care should pay particular attention to counseling on domestic violence, tobacco use, substance abuse, nutrition, and depression. Teens may also require additional assistance navigating the healthcare system and securing resources from social assistance programs. &
POSTPARTUM CONSIDERATIONS As with patients of all ages, postpartum care is an important component of comprehensive pregnancy care. There are three areas of postpartum care that require particular attention for adolescent patients: breastfeeding, depression, and repeat pregnancy.
documented, and organizations such as the WHO, the American Academy of Pediatrics, the American Congress of Obstetrics and Gynecology, and the US Preventive Services Task Force advise mothers to breastfeed infants for the first 6 months of life. However, adolescent mothers are less likely to breastfeed than older mothers. This is unfortunate, as adolescents themselves may benefit from breastfeeding. It is cost-effective, may result in increased inter-pregnancy intervals, and may foster motherinfant bonding. A longitudinal cohort of adolescent females (aged 14–21 years) and their male partners were observed from pregnancy through 6 months postpartum [20]. This study found that adolescents who initiated breastfeeding were more likely to have intended to breastfeed, to have partners who wanted them to breastfeed, and who had complications during labor and delivery. Interesting, greater social support was associated with significantly lower odds of breastfeeding. The unexpected finding of decreased breastfeeding initiation in adolescents with increased social support may indicate that increased support has the potential to interfere with the adolescent’s status as the infant’s primary caregiver. When examining the duration of breastfeeding, the majority of adolescents who initiated breastfeeding had stopped by 6 months – with the average duration of breastfeeding less than 6 weeks. Breastfeeding difficulty, obesity, and receiving women, infants, and children public assistance were associated with lower odds of exclusive breastfeeding. A retrospective population-based cohort study in Ohio confirmed that adolescent mothers (aged 20 years) [21]. Indicators of social support and socioeconomic stability were the most influential factors on lack of breastfeeding initiation; decreased rates were associated with being unmarried and having Medicaid as the primary insurance provider. Rates were also lower among adolescent mothers with premature births, which is concerning, given that premature infants may glean the largest benefit from breast milk. Inventions targeting breastfeeding initiation should target both the adolescent mother and their support systems. Future programs should also assess the complex dynamics of adolescent relationships and ongoing outpatient support networks.
Depression Breastfeeding The health, developmental, and psychosocial benefits of breastfeeding for the infant are well
Depression screening is a routine part of postpartum care for all women. It is especially important in the care of adolescent mothers, as the prevalence of
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postpartum depression among adolescent mothers is significantly higher compared to adult postpartum women. Postpartum depression affects both the mother and her developing infant. In a study of 180 adolescent African-American and Latino/Hispanic mothers, Huang et al. [22] found that higher levels of maternal depression are associated with greater developmental delays in infants at 18 months of age. Higher levels of parenting stress and less perceived social support were also associated with higher levels of depression at baseline in adolescent mothers. Clinicians who care for adolescent mothers and their children should make it a priority to implement screening into their patient care algorithms. A study by Venkatesh et al. [23 ] documented ways to easily screen for postpartum depression using variations of the Edinburgh Postnatal Depression Scale (EPDS). They found that the original 10-item EPDS, as well as two subscales (the EPDS-7, which focuses on depression symptoms, and the EPDS-2, which focuses on depressed mood and anhedonia) are accurate screening tools. These brief scales can be implemented into a busy clinical practice to help identify adolescent mothers with postpartum depression. &
Prevention of rapid repeat pregnancy and birth Adequate time between births lowers the risk of preterm births, low birth weight infants, and small for gestational age infants [24]. Rapid repeat births (defined as a pregnancy within 2 years of previous pregnancy) may pose even greater challenges to adolescent mothers than to their adult counterparts, as it becomes more difficult to attend school and pursue job opportunities with more than one teen pregnancy. Approximately 35% of recently pregnant adolescents have experienced a rapid repeat pregnancy; and two-thirds of these pregnancies were unintended [25 ]. It is troubling that nearly one in five teen births in 2010 was a repeat birth (defined as having two or more pregnancies resulting in a live birth before age 20) [26]. The prevalence of repeat teen births has decreased, from 19.5% in 2007 to 18.3% in 2010. However, racial/ethnic disparities persist with American Indian/Alaskan natives, Hispanics, non-Hispanic blacks experiencing the highest rates of repeat teen births. According to the Pregnancy Risk Assessment Monitoring System [27], which collects state-specific, population-based data on maternal attitudes and experiences before, during, and after pregnancy, 90.7% of adolescent mothers were &
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sexually active, 8% were not sexually active, and 1.3% were pregnant. Among those who were sexually active, approximately 76% used contraceptives and were more likely to use LARC methods than all sexually active teens (21.5 versus 4.5%). Adolescent mothers who were sexually active but not using contraception cited reasons for nonuse that included not wanting to use birth control, partner objections, inability to pay for birth control, and wanting to get pregnant. In a study of postpartum adolescents in seven states, using Pregnancy Risk Assessment Monitoring data, Wilson et al. [28] found that prenatal contraceptive counseling and attending a postpartum clinic visit were associated with a reduction in unprotected sex. Moreover, adolescents who attended a postpartum visit were more likely to report using hormonal contraception. In this cohort, 12% used LARC methods (11% used IUDs and 1% used implants). However, 14% of adolescent mothers did not return for a postpartum visit. The relatively high risk of losing an adolescent to follow-up after a delivery or abortion underscores the need to eliminate barriers to immediate LARC placement after a delivery or abortion. The optimal time of placement depends on several factors. While there is limited information regarding placement of an IUD immediately following delivery until about 4–6 weeks postpartum, the Centers for Disease Control and Prevention medical eligibility criteria categorizes IUD placement before 4 weeks postpartum as category 2 (benefits generally outweigh risks) [29]. Although there may be a slightly increased risk of IUD expulsion [30], continuation rates are higher in those who receive immediate placement [31–34]. Furthermore, the subdermal implant can be placed immediately following a delivery or abortion without any adverse effects on lactation or infant growth [35]. Baldwin and Edelman, in their review of the effect of LARC on rapid repeat pregnancy in adolescents, stress that adolescents should receive individualized, noncoercive counseling should begin during the prenatal period, and should lead to the opportunity to receive LARC methods immediately following delivery or abortion, or prior to discharge from the hospital. Those who intend to use LARC, but have a gap between the request and receipt of such a method, should be provided with non-LARC methods in the interim [36].
CONCLUSION Teen pregnancy and childbearing have significant social and economic impacts. Prevention of pregnancy is the first-line approach as most teen Volume 26 Number 5 October 2014
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Teen pregnancy: an update McCracken and Loveless
pregnancies are unplanned. Comprehensive sex education and counseling on contraception focused on increasing the use of LARC options are necessary to achieve this goal. It is encouraging that the prevalence of repeat teen births has decreased; however, significant racial/ethnic disparities persist. Teens who are sexually active and not using effective contraception have a very high likelihood of pregnancy within 1 year. Providers should counsel pregnant and parenting adolescents about the importance of adequate birth spacing, encourage the use of the most effective contraceptive methods, and encourage sustained contraceptive use. Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Shuger L. Teen pregnancy and high school dropout: what communities are doing to address these issues. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy and America’s Promise Alliance; 2012. Pregnancy and America’s Promise Alliance; 2012. 2. The National Campaign to Prevent Teen Pregnancy. Why it matters: Teen && pregnancy and overall child well-being. 2007. Washington, DC. United States nonprofit organization provides statistics on adolescent pregnancy, poll results and analyses of factors affecting teenage sexual behavior and sex education. The National Campaign challenges the nation to achieve by the year 2020, a reduction of 20% in the proportion of pregnancies among women under 30 years that are unplanned and a 20% reduction in the teen pregnancy rate. 3. Singh S, Darroch JE. Adolescent pregnancy and childbearing: levels and trends in developed countries. Fam Plann Perspect 2000; 32:14–23. 4. Penman-Aguilar A, Carter M, Snead MC, Kourtis AP. Socioeconomic disadvantage as a social determinant of teen childbearing in the U.S. Public Health Rep 2013; 128 (Suppl 1):5–22. 5. Martin JA, Hamilton BE, Osterman JK, et al. Births: final data for 2012. Natl & Vital Stat Rep 2013; 62:1–20. The report contains the most recent data on teen birth rates. 6. Cox S, Pazol K, Warner L, et al. Vital signs: births to teens aged 15– 17 years–United States, 1991–2012. MMWR Morb Mortal Wkly Rep 2014; 63:312–318. 7. Perper K, Peterson K, Manlove J. Diploma attainment among teen mothers. Fact sheet. Washington, DC: Child Trends; 2010. Available at: http://childtrends.org/wp-content/uploads/2010/01/child_trends-2010_01_22_FS_diplomaattainment.pdf. 8. Lepkowski J, Mosher W, Groves R, et al. Responsive design, weighting, and variance estimation in the 2006–2010 National Survey of Family Growth. Vital Health Stat 2103;2:2–52. 9. Finer JB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States. Fertil Steril 2012; 98:393–397. 10. National Campaign to Prevent Teen and Unplanned Pregnancy. Available at: http://thenationalcampaign.org/. 11. Peipert JM, Zhao Q, Allsworth J, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011; 117:1105–1113.
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