Nutritional, health and socio-demographic determinants of anaemia in adolescent girls in Kumbungu District, Ghana.

BACKGROUND: Anaemia is a serious health problem among adolescent girls in Ghana. The aims of this study were to measure the prevalence and identify the nutritional, health, and socio-demographic determinants of anaemia in adolescent girls in Kumbungu District, Northern Region, Ghana. METHOD: An analytical cross-sectional study involving 370 adolescent girls residing in Kumbungu district, selected using multi-stage sampling procedure, was conducted. A semi-structured questionnaire, 24-hr dietary recall, food frequency questionnaire, Food Insecurity Experience scale, and anthropometry were used to gather information on socio-demographic characteristics, nutrition knowledge, dietary diversity score, food consumption score, food consumption frequency, household food insecurity, and waist and hip circumferences. Haemoglobin was measured using a portable HemoCue hg 301 + Analyzer. Anaemia in the adolescent girls was defined as haemoglobin concentration less than 12 g/dl. Chi-square test and binary logistic regression analysis were used to identify the determinants of anaemia. RESULTS: The mean (± SD) age was 13.95 (± 2.94) years, and the majority of the girls were in school (79.5%) and lived in a rural area (81.1%). The mean (± SD) haemoglobin was 11.27 (± 1.19) g/dl, and 74.6% of the respondents had anaemia, with 1.6% having severe anaemia. The health determinant of anaemia was frequency of feeling nervous in the past 6 months [Adjusted Odds Ratio (AOR): 2.12: 95% Confidence Interval (CI): 1.17-3.89; p: 0.014], and the socio-demographic determinants were residential community status (AOR: 0.42; 95% CI: 0.24-0.75; p: 0.003), and fathers' educational qualification (AOR: 2.57, 95% CI: 1.17-5.65, p: 0.019). No nutritional determinants of anaemia were identified for this study population. CONCLUSION: The prevalence of anaemia was very high and the frequency of feeling nervous in the past 6 months, residential community status, and fathers' educational qualification were associated with anaemia among adolescent girls in Kumbungu district, Ghana. The prevalence of anaemia measured highlights the need for intensification of anaemia prevention and management interventions in the district.

Hot Feelings: Sexual Transference and Countertransference with Male Mid-Adolescents and a Female Psychoanalyst.

The author focuses on the workings of the female analyst-male pair in the consulting room when sexual feelings emerge as part of the adolescent storm. The need for open-bodiedness in relation to the perception of the bodily states of both the analyst and analysand is described and discussed. The author shows how somatic countertransference, reverie, and projective identification are harnessed creatively in the service of transformation. The importance of the third to help provide an analytic space for thought and meaning, rather than enactment and impasse, is discussed. The trajectory from the analyst's wish to silence sexual transference and countertransference in the consulting room, followed by the analyst's initial reluctance to discuss the hot feelings with colleagues, and then the impact of publication anxiety when writing through the experiences and revising this paper is described.

High-Yield HIV Testing, Facilitated Linkage to Care, and Prevention for Female Youth in Kenya (GIRLS Study): Implementation Science Protocol for a Priority Population.

BACKGROUND: Sub-Saharan Africa is the region with the highest HIV burden. Adolescent girls and young women (AGYW) in the age range of 15 to 24 years are twice as likely as their male peers to be infected, making females in sub-Saharan Africa the most at-risk group for HIV infection. It is therefore critical to prioritize access to HIV testing, prevention, and treatment for this vulnerable population. OBJECTIVE: Using an implementation science framework, the purpose of this research protocol was to describe the approaches we propose to optimize engagement of AGYW in both the HIV prevention and care continuum and to determine the recruitment and testing strategies that identify the highest proportion of previously undiagnosed HIV infections. METHODS: We will compare two seek recruitment strategies, three test strategies, and pilot adaptive linkage to care interventions (sequential multiple assignment randomized trial [SMART] design) among AGYW in the age range of 15 to 24 years in Homa Bay County, western Kenya. AGYW will be recruited in the home or community-based setting and offered three testing options: oral fluid HIV self-testing, staff-aided rapid HIV testing, or referral to a health care facility for standard HIV testing services. Newly diagnosed AGYW with HIV will be enrolled in the SMART trial pilot to determine the most effective way to support initial linkage to care after a positive diagnosis. They will be randomized to standard referral (counseling and a referral note) or standard referral plus SMS text message (short message service, SMS); those not linked to care within 2 weeks will be rerandomized to receive an additional SMS text message or a one-time financial incentive (approximately US $4). We will also evaluate a primary prevention messaging intervention to support identified high-risk HIV-negative AGYW to reduce their HIV risk and adhere to HIV retesting recommendations. We will also conduct analyses to determine the incremental cost-effectiveness of the seek, testing and linkage interventions. RESULTS: We expect to enroll 1200 participants overall, with a random selection of 100 high-risk HIV-negative AGYW for the SMS prevention intervention (HIV-negative cohort) and approximately 108 AGYW who are living with HIV for the SMART design pilot of adaptive linkage to care interventions (HIV-positive cohort). We anticipate that the linkage to care interventions will be feasible and acceptable to implement. Lastly, the use of SMS text messages to engage participants will provide pilot data to the Kenyan government currently exploring a national platform to track and support linkage, adherence to treatment, retention, and prevention interventions for improved outcomes. CONCLUSIONS: Lessons learned will inform best approaches to identify new HIV diagnoses to increase AGYW's uptake of HIV prevention, testing, and linkage to care services in a high HIV-burden African setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT02735642; https://clinicaltrials.gov/ct2/show/NCT02735642 (Archived by WebCite at http://www.webcitation.org/6vgLLHLC9).

Socioeconomic status, urine estrogens, and breast cancer risk.

Urine estrogens were measured in 46 women students, ages 15-18, at a middle-class high school in Athens and in 40 women of the same age residing at one of three orphanages in the same city. The lower socioeconomic status (SES) of the latter group was documented by their lower mean height (by 5.2 cm) and weight (by 5.3 kg) relative to the high school students. Both in follicular and luteal phases of the menstrual cycle, the women with lower SES had 50% higher estriol ratios (ratio of the concentration of estriol to the sum of the concentrations of estrone and estradiol). In luteal specimens the concentration of all three major estrogens was higher in the group with low SES than in the women in the other group, but the concentration of estriol was most increased. There was also an indication of less frequent anovular cycles among the women with low SES. These findings are consistent with hypotheses linking either the estriol ratio or the frequency of anovular cycles to breast cancer risk.

PIP: Urine estrogen levels were measured in 46 women students, ages 15-18, at a middle-class high school in Athens, Greece and in 40 women of the same age residing at 1 of 3 orphanages in the same city. The lower (SES) socioeconomic status of the latter group was documented by their lower mean height (by 5.2 cm) and weight (by 5.3 kg) relative to the high school students. Both in follicular and luteal phases of the menstrual cycle, the women with lower SES had 50% higher estriol ratios (ratio of the concentration of estriol to the sum of the concentrations of estrogens and estradiol). In luteal specimens, the concentration of all 3 major estrogens was higher in the group with low SES than in the women in the other group, but the concentration of estriol was most increased. There was also an indication of less frequent anovulan cycles among the women with low SES. These findings are consistent with hypotheses linking either the estriol ratio or the frequency of anovular cycles to breast cancer risk.

Serum and saliva cortisol relations in adolescents during pregnancy and the early postpartum period.

The purpose of this investigation was to examine: (1) relations between serum and saliva cortisol in adolescents in pregnancy and early postpartum and (2) short-term consistency of serum and saliva cortisol across three samples, 20 minutes apart, as well as the long-term consistency from pregnancy to early postpartum. Pregnant adolescents (n = 40), ages 14 to 19 years, were enrolled in this study. Subjects were seen at 20 weeks gestation or earlier (T1), 34-36 weeks gestation (T2), and 2-3 weeks postpartum (T3). Blood samples were drawn at T1 and T3, at 0, 20, and 40 minutes. Saliva samples were collected across the same 40-minute period at T1, T2, and T3. Spearman rho (rs) correlation coefficients between serum and saliva ranged from 0.72 to 0.77 (T1), and 0.42 to 0.60 (T3) (p < or = 0.05). Short-term consistency between serum cortisol samples was 0.86-0.97 at T1 and 0.60-0.82 at T3. Short-term consistency for saliva cortisol samples was 0.70-0.96 at T1, 0.91-0.95 at T2, and 0.64-0.89 at T3. Long-term consistency (T1 to T3) for serum and saliva cortisol was low. Individual differences as well as dramatic changes in the endocrine environment in pregnancy and the early postpartum period may explain the more moderate serum-saliva correlations in the postpartum period.

Identification of women at risk for unwanted pregnancy.

Concern about increasing rates of unwanted pregnancy, particularly among adolescents, has led to consideration of steps necessary to develop effective intervention programs. In order to reach a young woman for counseling and contraceptive assistance before she places herself at risk for unintended pregnancy, it seems necessary to develop the capability for identifying high-risk individuals without reference to sexual history. The authors describe a preliminary attempt to predict contraceptively unprotected coitus from responses to projective test stimuli, noting that the problem is so urgent that even early and necessarily incomplete work in this area may have merit in stimulating further research in identification of women at risk for unwanted pregnancy.

PIP: A trial series with a projective instrument was used with a sample of 85 women, aged 15-45, in an effort to stimulate other experimental and clinical efforts toward early identification of women at high risk for unwanted pregnancy. The overall strategy was to compare scores on the projective materia with a computerized behavioral measure of risking unwanted pregnancy in order to evaluate the discriminatory power of the projective test. The behavioral measure is a composite, machine-made variable that summarizes self-reported sexual behavior and feelings, and data for the behavioral measure were collected by a research assistance with no connection with the projective test scoring. I 2 of the 3 analyses, there was a statistically significant relationship between the projective test score and the behavioral measure of risk for unwanted pregnancy. On the basis of 1 modest trial, it seems that the role-redefinition criteria tap dimensions that are independent of usually described clinical syndromes. This research is not sufficiently advanced to be of general clinical value. There are problems with generalizability of the sample to the female population at large and standardization of scoring procedures.

Attributional style and depression in pregnant teenagers.

OBJECTIVE: Study 1 evaluated whether pregnancy is a stressful life event for teenagers and is associated with depression for teenagers with a pessimistic attributional style but not for those with an optimistic attributional style. Study 2 replicated unexpected findings from study 1. Study 3 evaluated whether pregnant teenagers with a pessimistic attributional style will be more depressed after childbirth than optimistic pregnant teenagers. METHOD: In study 1, 122 pregnant and 96 nonpregnant teenagers completed questionnaires assessing depression and attributional style. In study 2, 43 pregnant teenagers and 49 nonpregnant teenagers completed the same questionnaires. In study 3, subjects from studies 1 and 2 were contacted by mail and asked to complete the same questionnaires; 63 (38%) did so. RESULTS: In studies 1 and 2, pregnant teenagers with a pessimistic attributional style were less depressed than those with an optimistic attributional style and the nonpregnant group. In study 3, pessimistic teenagers experienced a higher level of depression than nonpessimistic adolescents following childbirth. CONCLUSIONS: Pregnancy may serve to protect pessimistic teenagers from experiencing depression. The subsequent demands of motherhood may remove any protection from depression afforded by the pregnancy. The experience of depression being relieved by another pregnancy may be a previously unidentified risk factor for repeated pregnancies in teenagers.

PIP: The association between attributional style and depression was explored in three studies of pregnant and nonpregnant adolescents recruited from clinics at the University of Texas (Galveston) Medical Branch. The first study examined the hypothesis that the stress of pregnancy would trigger depression in teenagers with a negative (pessimistic) attributional style but not in those with a positive (optimistic) attributional style. The Children's Attributional Style Questionnaire and the Beck Depression Inventory were administered to 122 pregnant and 96 nonpregnant adolescents 13-18 years old. Unexpectedly, both pregnant and nonpregnant teens with a pessimistic attributional style were less depressed than their counterparts with an optimistic style. The second study repeated the methodology of the first study in a sample of 43 pregnant and 49 nonpregnant teens and obtained the same result. The third study investigated the hypothesis that pregnant teens with a negative attributional style would be more depressed than optimistic pregnant teens after the birth of their infant. 63 of the pregnant teens who participated in the first two studies were enrolled. As expected, pessimistic teens experienced a higher level of depression than optimistic teens after childbirth. This finding suggests that, while pregnancy may temporarily mask depression in teenagers with a negative attributional style, the demands of motherhood remove this protection. The drive to escape depression may be a previously unidentified risk factor for repeat adolescent pregnancy.

Motivational factors in abortion patients.

PIP: From June 1970 through January 1971, a psychological comparison between 99 single white pregnant women seeking abortion and a control group of 79 single nonpregnant women of similar background showed that, as a group, the women seeking abortion were no more neurotic than nonpregnant women of the same ages. Both groups (comprised mainly of college students) were equally informed about contraceptives. 77% of the abortion group used no contraceptives prior to the pregnancy. 82% of the sexually active members of the control group consistently used contraceptives. Conscious motivational factors, such as guilt over use of contraception, reactions to loss, or severe acting-out character disorders, may have influenced the occurrence of the pregnancy in 40% of the abortion group. Psychological testing showed that the pregnant group stated themselves as more impulsive and as tending to externalize aggression.^ieng

The cost of successful adolescent growth and development in girls in relation to iron and vitamin A status.

The role of iron and vitamin A in adolescent growth and development is not well described. During adolescence iron requirements are increased, reaching a maximum at peak growth, but after menarche, menstrual iron loss must also be replaced. An observed rise in retinol-binding protein concentrations at puberty level 4 indicates a role for vitamin A in sexual maturation. Iron and vitamin A deficiencies may slow the tempo of growth. Conversely, for girls on marginal diets, an extended catch-up growth period may lead to depletion of these nutrients. The costs of achieving growth may also include cephalopelvic disproportion in girls becoming pregnant and increased risk of menorrhagia.

PIP: Few studies have investigated how nutrients such as iron and vitamin A promote adolescent growth or whether the effort of catching up on growth may result in a reduction of iron and vitamin A stores. The intake of these nutrients probably does not rise along with maturational requirements in many developing countries. In situations where adolescent females have a heavy workload, low social status, low priority in food distribution, and high infectious disease rates, growth may be achieved, but at the cost of reductions in stores of certain nutrients. Women's health will be compromised during pregnancy. It is proposed in this paper that growth requirements increase demands for iron and vitamin A and that deficiencies of these nutrients may be a consequence of growth and sexual development in adolescent females on marginal diets. One consequence of reduced iron and vitamin A stores in nonpregnant adolescents may be increased risk of menorrhagia, which contributes further to the problems of anemia in poorly nourished girls in their prereproductive years and beyond. The costs of achieving growth may also include cephalopelvic disproportion in girls becoming pregnant. Sections discuss iron and vitamin A requirements during adolescence, the cost of successful growth, and interactions of vitamin A and iron.

Reproductive histories of low weight girls and women.

As shown in 79,000 girls and women participating in four different surveys, low body weight (less than or equal to 47.2 kg) does not prevent the attainment of menarche, conception, or even repeated conceptions. Indeed, low body weight is especially common in early maturing girls and in Puerto Ricans and Mexican-Americans. From these data, the concept of a "critical weight" for menarche is difficult to substantiate, although low body weight does have nutritional implications and is the second most important factor in regulating fetal growth.

PIP: As shown in 79,000 girls and women participating in 4 different surveys, low body weight less than or equal to (47.2 kg) is without influence in preventing the attainment of menarche, conception, or even repeated conceptions. Indeed, low body weight is especially common in early maturing girls and in Puerto Ricans and Mexican Americans. From these data, the concept of a "critical weight" for menarche is difficult to substantiate, although low body weight does have nutritional implications and is the 2nd most important factor in regulating fetal growth.

Effects of increased dietary calcium intake upon the calcium and bone mineral status of lactating adolescent and adult women.

We studied the effectiveness of an increased calcium (Ca) diet in preventing bone mineral loss in lactating adolescent mothers. Three groups of lactating women were studied: 15 control adolescents consuming their usual Ca diet (900 mg/d), 21 experimental adolescents consuming a high-Ca diet (greater than 1600 mg/d), and 12 adults. At 2 and 16 wk postpartum, serum calcium, phosphate, magnesium, albumin, alkaline phosphatase, vitamin D, parathyroid hormone (PTH), and calcitonin (CT) were determined. Bone mineral analyses were performed by photon absorptiometry. By 16 wk the control adolescent group had a 10% decrease in bone mineral content (BMC) and increased PTH and CT. The experimental adolescent and adult groups had no significant change in BMC during the study. There was a positive correlation (r = 0.45, p less than 0.01) between dietary Ca intake and BMC in all adolescents. Data suggest that bone loss during lactation in adolescents may be prevented with adequate dietary Ca intakes.

Comparison of the nutritional status of pregnant adolescents with adult pregnant women. III. Maternal protein and calorie intake and weight gain in relation to size of infant at birth.

Factors influencing the outcome of pregnancy were studied in 98 women, ages 12 to 32, divied into four age groups. A significantly higher weight gain was recorded for the youngest age group and the lowest gain for the oldest age group. The amount of weight gained was a function of length of gestation, but was not influenced by calorie intake of the mother. Neither was there significant correlation between protein and calorie intake of the mother and the infant's birth weight. Mean calorie intakes averaged below and mean protein intakes above the 1974 RDA. About 10% of the infants weighed less than 2,500 g and no single factor could be identified as the cause of low birth weight.

PIP: 98 pregnant women, aged 12-32, were studied to determine factors influencing the outcome of pregnancy. A comparison of the nutritional status of pregnant adolescents with adult pregnant women was made. Data on the age of the mother at conception, the week of delivery, her weight gain, her protein and calorie intakes, the size of infant at birth, and the Apgar Score of the infant were used. A significantly higher weight gain was recorded for the youngest group (12-17 years) and the lowest gain for the oldest group (25-32 years). The interaction between age and length of pregnancy was also significant (p less than .028). Calorie intake was unrelated to the amount of weight gained. Weight gain was, however, a function of length of gestation. Calorie and protein intake of the mother was an insignificant factor affecting the infant's birth weight. Low birth weight in about 10% of the infants was untraced to any single factor studied.

Maternal nutritional status and adolescent pregnancy outcome.

To investigate the determinants of low birth weight of infants born to adolescent mothers, we studied the obstetric population attended at the Maternity Hospital of Lima, Peru. From this population we selected for study a sample of 1256 adolescent mothers ranging in age from 12 to 25 yr. The study included anthropometric and biochemical measurements used to evaluate nutritional status and physiological maturity of the mother and newborn. Findings from the present research indicate that the low birth weight of infants born to adolescent mothers is not due to premature delivery (short gestation) or low gynecological maturity. Furthermore, young adolescent mothers had smaller and thinner newborns than those born to older women who were adjusted for nutritional status during pregnancy and at delivery. That is, despite the similar nutritional status among the young adolescent mothers, the availability of nutrients for the accumulation of calories in the fetus (measured by skinfold thickness) was less than that of older women. Furthermore, the pregnancy weight gain associated with an optimal or average newborn weight is greater for young teenagers than for older women. These findings support the hypothesis that among rapidly growing teenagers the nutritional requirements of pregnancy may be greater than those of older women, and that this increased requirement competes with the growth needs of the fetus.

Adolescent maternal weight gain and low birth weight: a multifactorial model.

Maternal weight gain is one of the most important independent predictors of infant birth weight and interacts with other maternal characteristics, including age, so that infant birth weight reaches a plateau at a higher level of maternal weight gain for young adolescents than for adults. It has been suggested that encouraging young adolescents to gain larger amounts of weight during pregnancy may be one way to decrease their risk of low-birth-weight deliveries. This recommendation may be premature because the mechanisms underlying the interaction between maternal age and weight gain are incompletely understood and may include such diverse factors as incomplete maternal growth, reproductive immaturity, diminished maternal body size, nutritional deficiencies, socioeconomic and behavioral factors, and maternal emotional stress. This review summarizes the literature on adolescent maternal weight gain and infant birth weight and discusses the importance of considering a multifactorial model in reformulating the weight-gain recommendations for pregnant adolescents.

PIP: Maternal weight gain is one of the most important independent predictors of infant birth weight and interacts with other maternal characteristics, including age, so that infant birth weight reaches a plateau at a higher level of maternal weight gain for young adolescents than for adults. It has been suggested that encouraging young adolescents to gain larger amounts of weight during pregnancy may be 1 way to decrease their risk of low-birth-weight deliveries. This recommendation may be premature because the mechanisms underlying the interaction between maternal age and weight gain are incompletely understood and may include such diverse factors as incomplete maternal growth, reproductive immaturity, diminished maternal body size, nutritional deficiencies, socioeconomic and behavioral factors, and maternal emotional stress. This review summarizes the literature on adolescent maternal weight gain and infant birth weight and discusses the importance of considering a multi-factorial model in reformulating the weight-gain recommendations for pregnant adolescents. More must also be learned about the relationship between the pattern of maternal weight gain and fetal growth and development. The pattern of tissue growth during gestation suggests that the effect of nutritional supplementation may change during gestation. The history of neonatal intensive care is punctuated by therapeutic misadventures. If similarly devastating complications are to be avoided in the futrue, the risks of cephalopelvic disproportion, cesarian section, and birth asphyxia associated with augmented fetal growth must be clearly defined and contrasted with the risks associated with low-birth-weight delivery in adolescent pregnancy.

Young maternal age and preterm labor.

PURPOSE: The relationship among young age, biologic immaturity (as indexed by low gynecologic age), and the causes of preterm delivery (idiopathic preterm labor [PTL], premature rupture of the membranes [PROM], and medical indications) were investigated among 605 primigravidas from the Camden Study. METHODS: The sample consisted of 366 young adolescents < 16 years at the time of their last menstrual period (LMP) and 239 older women, 18-29 years at LMP (controls). The young adolescents were significantly shorter, thinner, had younger ages at menarche, and over a third (36.3%) were of low gynecologic age, i.e., their chronologic age was 2 or fewer years more than their age at menarche. RESULTS: Adjusting for ethnicity, cigarettes smoked/day, weight gain rate, height, fetal sex, gestational diabetes mellitus, and pregnancy-induced hypertension, young adolescents overall had a nearly 75% increased risk of PTL (adjusted odds ratio [AOR] = 1.74, 95% confidence interval [95% CI]: 1.07-2.84), and preterm delivery with PTL (AOR = 2.08, 95% CI: 1.08-4.00). There was a modest decreased risk of preterm delivery among young gravidas attributable to other causes, such as PROM or medical indications (AOR = 0.70, 95% CI: 0.28-1.75). This increased risk of PTL and preterm delivery with PTL was principally attributable to biologic immaturity. Young age with low gynecologic age was associated with a twofold risk of PTL (AOR = 2.15, 95% CI: 1.19-3.89) and preterm delivery with PTL (AOR = 2.64, 95% CI: 1.23-5.65), while the risk associated with young age and higher gynecologic age was only increased moderately. CONCLUSIONS: Young adolescents, and especially those of low gynecologic age, appear prone to PTL and are at increased risk for preterm delivery through this pathway.

PIP: The relationship between young maternal age and preterm delivery was investigated in a subsample of 605 primigravidas enrolled in the Camden (New Jersey, US) Study. Included were 366 adolescents under 16 years of age (cases) and 239 women 18-29 years of age (controls). 36.3% of young mothers had a low gynecological age (i.e., their chronological age was 2 or fewer years more than their age at menarche). After adjustment for ethnicity, cigarette smoking, weight gain rate, height, fetal sex, gestational diabetes mellitus, and pregnancy-induced hypertension, the odds ratio (OR) of preterm labor among young adolescents was 1.74 (95% confidence interval (CI), 1.07-2.84) and that of preterm delivery was 2.08 (95% CI, 1.08-4.00). There was a modest decreased risk of preterm delivery attributable to other causes (e.g., premature rupture of the membranes) among the youngest women (OR, 0.70; 95% CI, 0.28-1.75). Young age with low gynecological age was associated with a 2.15 OR (95% CI, 1.19-3.89) of preterm labor and a 2.64 OR (95% CI, 1.23-5.65) of preterm delivery with preterm labor. The risk associated with young age and higher gynecological age was increased only moderately. These findings suggest that it is the biological immaturity often associated with young age, rather than young maternal age per se, that increases the risks of adolescent pregnancy. The association between low gynecological age and preterm labor is presumed to reflect an irritability of the adolescent uterus, a sensitivity to dehydration, and/or an altered hormonal milieu that promotes maternal development at the expense of fetal well-being.

Levonorgestrel contraceptive implants in female patients 14 to 21 years old.

OBJECTIVE: To determine which factors are associated with duration of use of a levonorgestrel implant (Norplant) for contraception in adolescents and young adults. DESIGN: We retrospectively studied 144 young women (14 to 21 years of age) who chose a levonorgestrel contraceptive implant at Mayo Clinic Rochester between April 1990 and December 1993. MATERIAL AND METHODS: The following information was obtained at the time of insertion of the implant and from any follow-up visits: demographics, prior contraceptive experiences, frequency and management of complications, complications noted at removal of the implant, and subsequent contraceptive choice. The duration of use was examined. RESULTS: Of the 144 young women who underwent insertion of a Norplant system, 75 telephoned or made a medical appointment because of implant-related side effects. During the follow-up period, 64 patients had the Norplant system removed. The Kaplan-Meier estimate of the probability of the Norplant system remaining in place for at least 12 months was 83 % and for at least 24 months was 63 %. Duration of Norplant use was not found to differ with respect to age, prior contraceptive use, or timing of insertion, but it was significantly shorter among those with a prior pregnancy than in those who had never been pregnant. CONCLUSION: These findings suggest that a group of young women who are likely to continue use of a contraceptive implant (with or without treatment for side effects) are those who have never been pregnant.

PIP: A retrospective study of 144 US women 14-21 years of age who requested and received the Norplant contraceptive implant system at the Mayo Clinic (Rochester, Minnesota) in 1990-93 analyzed the factors associated with duration of method use. Of the 124 women who reported past use of contraception, 94 (76%) had been pregnant at least once. The method most commonly used before Norplant was oral contraception (57%). The reasons for Norplant selection were its convenience (86%) and problems tolerating the pill (14%). Of the 130 Norplant users who either telephoned or made a clinic appointment after insertion, 60% reported side effects such as breakthrough bleeding, headache, and depression or mood swings. 64 women had the implants removed. The median duration of Norplant use was 29 months. The Kaplan-Meier estimate of the probability of the Norplant system remaining in place for at least 12 months was 83% and 63% for at least 24 months. Age, prior contraceptive use, and timing of insertion had no impact on duration of Norplant use. Multivariate analysis indicated that women with at least 1 prior pregnancy had a two-fold increased risk of Norplant removal compared to those who had never been pregnant. Larger studies are needed to identify additional factors associated with long-term use of injectable contraception among young women and to suggest interventions that would improve compliance with routine follow-up.

Cortisol reactivity and anxiety and depression in pregnant adolescents: a longitudinal perspective.

The purpose of this investigation was to examine: (1) the relations among cortisol reactivity (short term changes in cortisol concentration) and anxiety and depression symptoms in adolescents during pregnancy and early postpartum, and (2) cortisol reactivity and psychosocial variables as predictors of anxiety and depression symptoms in pregnancy and early postpartum. Cortisol reactivity, an index of hypothalamic-pituitary-adrenal activity, was hypothesized to be a vulnerability factor for poor physical and mental health outcomes in adolescents. Forty adolescents aged 14 to 19 years (M = 17.3, SD = 1.3) were enrolled in the study and were seen at < 20 weeks gestation (T1), 34-36 weeks gestation (T2), and 2-3 weeks postpartum (T3). Blood was drawn for cortisol at T1 and T3. Psychological assessments of anxiety and depression symptoms, life optimism, and self-worth were administered at T1, T2, and T3. There were significant correlations among cortisol reactivity and anxiety and depression symptoms at T1 and T3, but the correlations were the reverse of the hypothesized direction. Pregnant adolescents with increased cortisol reactivity (cortisol concentrations that increased across a 40-min period) had fewer symptoms of anxiety and depression than other adolescents. Longitudinal analyses showed that anxiety and depression symptoms at T1 were a stronger predictor of postpartum anxiety and depression than was cortisol reactivity, life optimism, self-worth, or age at pregnancy.

PIP: The authors hypothesized cortisol reactivity to be a vulnerability factor for poor physical and mental health outcomes in adolescents. This paper reports findings from a study of the relations among cortisol reactivity and anxiety and depression symptoms in pregnancy and early postabortion. 40 adolescents aged 14-19 years were enrolled in the study and seen at less than 20 weeks gestation, 34-36 weeks gestation, and 2-3 weeks postpartum. Blood was drawn for cortisol at the 1st and 3rd time indexes. At all times, psychological assessments of anxiety and depression symptoms, life optimism, and self-worth were administered. Significant correlations were found among cortisol reactivity and anxiety and depression symptoms at T1 and T3, but in a direction opposite of that which was hypothesized. Pregnant adolescents with increased cortisol reactivity had fewer symptoms of anxiety and depression than other adolescents. Longitudinal analyses further demonstrated that anxiety and depression symptoms at T1 were stronger predictors of postpartum anxiety and depression than were cortisol reactivity, life optimism, self worth, or age at pregnancy.

Blood pressure levels of Zambian rural adolescents and their relationship to age, sex, weight, height and three weight-for-height indices.

A study of blood pressure levels of 372 rural Zambian schoolchildren age 7-16 years showed that blood pressure increases with age. The association between age and blood pressure is decreased when growth is controlled for in the analysis. Girls tended to have either the same or slightly higher mean blood pressure levels at all ages than boys. The main determinants of blood pressure in the children were age, height and weight. Mean systolic blood pressure (SBP) values of the children were lower than those for Nigerian, American and worldwide adolescents of comparable age, whereas mean diastolic blood pressure values were similar to those of American and worldwide adolescents of comparable age. The associations between blood pressure and the three indices commonly used to measure relative obesity, i.e. weight-for-length, weight/height2 and weight/height,3 were only significant for weight-for-length after adjusting for height, suggesting that the other two indices may not be appropriate in studies focussed on children and should be applied with caution. The nonsignificant associations observed between blood pressure and the other two weight-for-height indices may be attributed to the almost nonexistence of obesity in this sample of children.

PIP: A researcher used data on 372 7-16 year old children from 2 rural primary schools in Zambia collected between October 1986-June 1988 to learn blood pressure levels in health school age children and to see of an association between blood pressure and age, sex, height, and weight exists. Overall blood pressure increased gradually with age (p.05), but when the researcher controlled for growth, the association between age and blood pressure diminished. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) of girls either remained the same or were higher than those of boys which may be explained by hormonal and other changes during puberty. Age, height, and weight were the leading determinants of blood pressure (p.001). The Zambian children's mean SBP levels stood lower than those of Nigerian and US children of comparable age and those from children worldwide of comparable age, but DBP levels paralleled those of US and worldwide children. After the researcher adjusted for height, blood pressure was only significant with weight for length (p.05), but not with the other indices used to measure relative obesity (weight/height sq. and weight/height cubed). Thus these 2 other indices may not be applicable to studies on children. Further the nonsignificance of blood pressure with these other 2 indices may indicate limited obesity among these children.

Sexually transmitted diseases and oral contraceptive use during adolescence.

Sexually transmitted diseases (STD) cause lower genital tract infections (cervicitis, vaginitis) or ascending infections of the fallopian tubes, and, possibly, pelvic inflammatory disease (PID). The syphilis bacterium, human immunodeficiency virus (HIV), and the hepatitis virus cause systematic disease. Although oral contraceptives (OCs) are the most reliable contraceptive method, they have limited anti-STD properties and their relationship with STDs remain unclear. Various mechanisms explain a protective role of OCs against STDs; however, in no way can OCs be considered a safe anti-STD contraceptive method, when compared to specific barrier methods, which provide both contraception and anti-STD protection. The above has been confirmed by a recent study performed in our institution where 10.3% and 6.9% of OC users presented a prevalence of Chlamydia trachomatis and Mycoplasma, respectively, when compared to 0% and 4.5% infection rates found among condom users. It is concluded that although OCs possess some anti-STD properties, mainly in the prevention of PID, they should be used in combination with a barrier method.

Oral contraceptive compliance during adolescence.

PIP: A review of the available literature suggests that adolescent lack of compliance with oral contraceptives (OCs) is a multifactorial problem that requires a multifactorial solution. Because of their lack of experience with contraception, higher frequency of intercourse, higher intrinsic fertility, and pattern of frequent stopping or switching of methods, adolescents experience higher OC failure rates than do adult women. Adolescents also are more likely to forget to take the pill or to discontinue due to side effects, without consulting their physician. A survey of European young women identified contraceptive protection without weight gain as the most necessary change in OCs. Adolescents must be counseled not to miss a single pill, observe the pill-free interval, take phasic formulations in the right order, and use a back-up method in case of diarrhea and vomiting or when certain medications (e.g., antibiotics and anti-epileptics) are used concurrently, and be informed of steps to take in the event of side effects and unprotected intercourse. The quality of the counseling appears to be more important to compliance than the quantity of information provided. Pharmacists should complete the counseling initiated by the physician and explain prescription use. The most significant predictor of consistent OC use is the adolescent's motivation.^ieng