Adolescents' intention to use long-acting reversible contraception postpartum.

STUDY OBJECTIVE: Multiparous teens, compared to primiparous teens, are at increased risk for adverse neonatal and maternal outcomes. Long-acting reversible contraception (LARC) is infrequently used among postpartum teens. This study identifies predictors of teens' intentions to use LARC postpartum when it is widely available. METHODS: Colorado teens who were patients during their pregnancy in an adolescent-centered clinic where all common methods of contraception were easily accessible were surveyed in clinic during their third trimester and following delivery regarding life circumstances (relationships, stress, and family function) and intended method of postpartum contraception. Multinomial logistic regression analyses were used to examine predictors of intended postpartum contraceptive method: LARC, non-LARC effective (condoms, birth control pills, shot, patch, or ring), or low-effective method or no contraception (abstinence, no method, or undecided). RESULTS: 1,203 patients were enrolled. Greater life stress was associated with greater likelihood of intending to use low-effective contraception versus LARC postpartum. Teens in a longer relationship with their baby's father (versus those never in a relationship with the baby's father) were less likely to intend to use low-effective contraception or non-LARC effective methods and more likely to intend to use LARC postpartum. CONCLUSION: When structural barriers are minimized, non-clinical factors such as relationship context and life stress are most associated with postpartum LARC use intentions. Health care providers can help teen patients obtain the postpartum contraception the patients believe is best by employing developmentally appropriate, person-centered care that is sensitive to life stressors and relationship context.

The perceived impact of a post-Dobbs landscape on U.S. adolescents and young adults.

OBJECTIVE(S): To capture the perspectives and knowledge of adolescents and young adults on abortion-related topics following the Dobbs decision. STUDY DESIGN: Qualitative content analysis of an open-ended, five-question survey fielded on October 28, 2022 via the MyVoice project, a nationwide weekly text message poll of 14-24-year-olds. RESULTS: We found the respondents (N = 565, response rate 71%) had a mean age of 20.0 years and resided in 47 states. Many described pro- or anti-abortion changes to abortion access in their state, though expressed mixed emotions about the changes (negative, positive, or mixed/neutral). Most often, they had conversations about abortion with peers (28%), followed by parents or family (20%); nearly 20% stated they have never had a conversation about abortion. The majority of respondents (55%) believed they and their peers should have access to abortion care without required parental consent/notification, frequently citing individual rights/autonomy (31%) followed by harms of parental involvement (12%). Most (79%) provided a technique for how to determine if online information about abortion was trustworthy. CONCLUSION(S): Four months after the Dobbs decision, this national sample of adolescents and young adults were aware of changes to abortion access, had conversations about abortion, shared diverse opinions on parental consent or notification laws, and could determine trustworthiness of online abortion resources. Abortion-related policy and practice can be improved by understanding adolescents' and young adults' needs and preferences, trusting and supporting their autonomy, and reducing barriers to care. IMPLICATIONS: This study highlights the timely perspectives and experiences of a diverse, nationwide sample of adolescents and young adults on abortion-related topics. Findings can support centering adolescents and young adults in practice and policy changes to improve their knowledge about abortion and streamline access to essential reproductive health services post-Dobbs.

Development of a clinical questionnaire to support contraception decisions in an adolescent reproductive health clinic in Colorado.

CONTEXT: Adolescents need support to make informed decisions about contraception. Few clinical questionnaires exist to help adolescents and their healthcare providers align contraception decisions with patient needs and preferences. METHODS: Our mixed-methods study involved a convenience sample of English-speaking, female patients aged 13-19 seeking contraception services at an adolescent reproductive health clinic in Colorado, USA. Qualitative interviews informed development of clinical questionnaire items. The questionnaire elicited demographic characteristics, pregnancy and contraception use history, preferred contraception attributes, peer and family involvement, healthcare information and support needs, motivations for contraceptive use, and barriers to contraceptive services. We identified key decision-making factors and reduced the number of questionnaire items through principal components analysis. Using multivariable analyses, we examined the correlation between questionnaire responses and current contraceptive method. RESULTS: Twenty individuals participated in interviews and 373 individuals completed the preliminary questionnaire with 63 candidate items. We identified five contraceptive decision-making factors: side-effect avoidance (eight items, Cronbach's alpha = 0.84), preferred method attributes (six items, Cronbach's alpha = 0.67), parental involvement (three items, Cronbach's alpha = 0.67), life goals prior to parenting (four items, Cronbach's alpha = 0.88), and access to a contraceptive provider (two items, Cronbach's alpha = 0.92) and nine stand-alone items. In multivariable analyses, we found that questionnaire responses for decision-making factors varied among participants using different contraceptive methods. CONCLUSIONS: Multiple priorities may influence adolescent contraceptive decisions. This clinical questionnaire can elicit these priorities before or during a healthcare encounter. Future studies should assess generalizability of the questionnaire and examine impact on method choice, continuation, satisfaction, and reproductive health outcomes.

"Time and money and support": Adolescents and young adults' perceived social and logistical support needs for safe abortion care.

OBJECTIVE: To understand what support adolescents and young adults need to access abortion amidst the changing legal landscape. STUDY DESIGN: A diverse nationwide sample (N = 638, response rate 78%) of individuals aged 14-24 responded to a text message survey in July 2022 about the social and logistical support they would need for safe abortion access. Responses were coded and analyzed thematically. RESULTS: Respondents described parents and friends as primary sources of social support for potential abortion decisions. They frequently cited money and transportation as logistical support needs for out-of-state abortion care. CONCLUSIONS: Adolescents and young adults report needing social support and specific resources to ensure access to abortion. IMPLICATIONS: This study highlights the perspectives and experiences of a diverse, nationwide sample of adolescents and young adults on their perceived abortion-related social and logistical support needs. These findings can support centering adolescents and young adults in practice and policy change to minimize barriers, improve social support, tailor resources and information about abortion, and streamline access to essential reproductive health services in a post-Dobbs landscape.

A Nationwide Sample of Adolescents and Young Adults Share Where They Would Go Online for Abortion Information After Dobbs v. Jackson.

PURPOSE: Given the changing landscape of abortion access, we sought to understand where adolescents and young adults retrieve information about abortion online. METHODS: A nationwide sample (n = 638) of 14- to 24-year-olds responded to a qualitative text message survey in July 2022 regarding websites or social media they would use for abortion-related information. Open-ended responses were coded and analyzed for themes. RESULTS: Forty-six percent of respondents (n = 234) named specific websites or accounts of known organizations or individuals; 14% named general clinical or governmental resources; and 13% named social media platforms. Eight percent expressed skeptical sentiments about online abortion information. 17% (n = 99) said they were not sure or did not have an opinion. DISCUSSION: Many adolescents and young adults could name an online resource for abortion information, but some are not aware of specific resources, underscoring a need to elevate reputable sources and provide guidance on how and where to look for accurate online abortion-related information.

Adolescent Awareness of the Changing Legal Landscape of Abortion in the United States and Its Implications.

PURPOSE: Restrictions on abortion in the United States will have disproportionate and negative impacts on adolescents. Prior to the Supreme Court ruling to overturn federal protection of abortion, we sought to examine adolescents' awareness and knowledge about the legal landscape of abortion and how changes might affect them. METHODS: We fielded a 5-question open-ended survey via text message to a nationwide sample of adolescents aged 14-24 years on May 20, 2022. We coded the responses using inductive consensus coding. Summary statistics were calculated for code frequencies and demographic data, and analyzed qualitatively using visual inspection of results overall and by subgroups (e.g., age, race and ethnicity, gender, and restrictiveness of state of residence). RESULTS: A total of 654 responded (79% response rate), of which 11% were under 18 years. Most adolescents were aware of potential changes to abortion access. Most adolescents reported using the internet and social media for information about abortions. Overall, negative emotions about the changing legal landscape predominated, including anger, fear, and sadness. When considering factors for abortion decisions, adolescents most often discussed finances and life circumstances including their future, age, education, maturity, and emotional stability. Themes were relatively, uniformly distributed across subgroups. DISCUSSION: Our study suggests that many adolescents are aware of and concerned about potential impacts of abortion restrictions, across a diversity of ages, gender, racial/ethnic, and geographic perspectives. Understanding and amplifying the voices of adolescents during this critical time is necessary to inform novel access solutions and policy initiatives that center the needs of youth.

Minors' Experiences Accessing Confidential Contraception in Texas.

PURPOSE: Texas is one of 24 states that restricts minors' ability to obtain contraception without parental consent, unless they access confidential services at federally funded Title X clinics. This study explores Texas minors' reasons for and experiences seeking confidential contraception. METHODS: Between September 2020 and June 2021, we conducted in-depth phone interviews with 28 minors aged 15-17 years. Participants were recruited via the text line and Instagram account of an organization that helps young people navigate Texas' parental consent laws. Interview transcripts were coded and analyzed using inductive and deductive codes in our thematic analysis. RESULTS: Participants wanted to be proactive about preventing pregnancy by using more effective contraceptive methods but faced resistance from adults when they initiated conversations about sex and contraception or tried to obtain consent. In the absence of adult support, they turned to online and social media resources for information about types of contraception but encountered challenges finding accurate information about where to obtain methods in Texas without a parent. Only 10 participants were able to attend an appointment for contraception. Parents' increased monitoring of minors' activities during the COVID-19 pandemic, combined with transportation and appointment-scheduling barriers, made it difficult for minors to attend in-person visits, particularly if clinics were farther away. DISCUSSION: Minors in Texas faced a range of barriers to finding accurate information and obtaining confidential contraceptive services, which were exacerbated by the COVID-19 pandemic. Expanding options for accessible confidential contraception, along with repealing parental consent laws, would better support minors' reproductive autonomy.

Association Between Publicly Funded Contraceptive Services and the Abortion Rate in Texas, 2010-2015.

OBJECTIVE: To evaluate how the availability of contraceptive services was associated with a change in the abortion rate before and after Texas' legislative changes to the family planning budget in 2011 and abortion access in 2013. METHODS: In this cross-sectional study, we obtained 2010 and 2015 data on contraceptive provision (number of publicly funded clinics and number of contraceptive clients served per 1,000 reproductive-aged women) from the Guttmacher Institute and county-level abortion data from the Texas Department of State Health Services. We categorized counties as having an abortion rate that increased or declined less than the national rate between 2010 and 2015 ( low-decline counties ) compared with those having an abortion rate that declined equal to or greater than the national rate between 2010 and 2015 ( high-decline counties ). We evaluated differences in contraceptive provision between high-decline and low-decline counties and evaluated county characteristics (racial and ethnic composition, unemployment, poverty, uninsured, education, distance to an abortion clinic, deliveries covered by Medicaid, and Catholic hospital marketplace dominance) as potential confounders. RESULTS: Of 157 counties that had at least one contraceptive clinic in either 2010 or 2015, 49 were low-decline counties and 108 were high-decline counties. Although the total number of publicly funded family planning clinics increased by 10.8%, there was a 4.7% decrease in the total number of contraceptive clients served statewide. Compared with low-decline counties, high-decline counties had a higher median number of contraceptive clients served per 1,000 women aged 18-44 years (31.9 vs 60.7, P <.05) in 2015. Between 2010 and 2015, the abortion rate decreased 19.7% for each 1.0% increase in contraceptive clients served. CONCLUSION: Texas counties with higher abortion-rate declines had more publicly funded contraceptive clinics and served more contraceptive clients than counties with lower declines, which may indicate the importance of greater access to publicly funded contraceptive services.

Gender inequality, women's empowerment, and adolescent birth rates in 363 Latin American cities.

BACKGROUND: Gender inequality is high in Latin America (LA). Empowering girls and young women and reducing gender gaps has been proposed as a pathway to reduce adolescent pregnancy. We investigated the associations of urban measures of women's empowerment and gender inequality with adolescent birth rates (ABR) in 366 Latin American cities in nine countries. METHODS: We created a gender inequality index (GII) and three Women Achievement scores reflecting domains of women's empowerment (employment, education, and health care access) using censuses, surveys, and political participation data at city and sub-city levels. We used 3-level negative binomial models (sub-city-city-countries) to assess the association between the GII and scores, with ABR while accounting for other city and sub-city characteristics. RESULTS: We found within country heterogeneity in gender inequality and women's empowerment measures. The ABR was 4% higher for each 1 standard deviation (1-SD) higher GII (RR 1.04; 95%CI 1.01,1.06), 8% lower for each SD higher autonomy score (RR 0.92; 95%CI 0.86, 0.99), and 12% lower for each SD health care access score (RR 0.88; 95%CI 0.82,0.95) after adjustment for city level population size, population growth, homicide rates, and sub-city population educational attainment and living conditions scores. CONCLUSION: Our findings show the key role cities have in reducing ABR through the implementation of strategies that foster women's socioeconomic progress such as education, employment, and health care access.

Adolescent birth rates and the urban social environment in 363 Latin American cities.

INTRODUCTION: Latin America has the second-highest adolescent birth rate (ABR) worldwide. Variation between urban and rural areas and evidence linking country development to ABR points towards upstream factors in the causal pathway. We investigated variation in ABR within and between cities, and whether different features of urban social environments are associated with ABR. METHODS: We included 363 cities in 9 Latin American countries. We collected data on social environment at country, city and subcity levels and birth rates among adolescents (ages 15-19). We investigated variation in ABR within and between countries and cities along with associations between social environment and ABR by fitting three-level negative binomial models (subcities nested within cities nested within countries). RESULTS: The median subcity ABR was 58.5 per 1000 women 15-19 (IQR 43.0-75.3). We found significant variability in subcity ABR between countries and cities (37% of variance between countries and 47% between cities within countries). Higher homicide rates and greater population growth in cities were associated with higher ABR (rate ratio (RR) 1.09; 95% CI 1.06 to 1.12 and RR 1.02; 95% CI 1.00 to 1.04, per SD, respectively), while better living conditions and educational attainment in subcities were associated with lower ABR after accounting for other social environment characteristics (RR 0.95; 95% CI 0.92 to 0.98 and 0.78; 95% CI 0.76 to 0.79, per SD, respectively). CONCLUSIONS: The large heterogeneity of ABR found within countries and cities highlights the key role urban areas have in developing local policies. Holistic interventions targeting education inequalities and living conditions are likely important to reducing ABR in cities.

The Pediatrician in the Post-Roe Landscape.

This Viewpoint discusses adolescent and young adult reproductive health care in a post-Roe environment.

Post-Pregnancy Factors Predicting Teen Mothers' Educational Attainment by Age 30 in Two National Cohorts.

Women who begin childbearing as teenagers attain lower levels of education than women who delay childbearing until age 20 and later. Little is known about post-pregnancy factors that predict educational attainment among teen mothers. The current study examined whether teen mothers' environment and experiences 2 years after their first birth contribute to their educational outcomes by age 30, net of selection factors associated with teenage childbearing. Data were from two cohorts, the National Longitudinal Surveys of Youth 1979 (N = 241) and 1997 (N = 378). Multinomial logistic regression modeling was used to assess associations of post-pregnancy factors with teen mothers' educational attainment. Having child care was associated with increased odds of attaining a high school diploma and of attending college in both cohorts. Providing regular and subsidized child care for teen mothers is an opportunity to support teen mothers in achieving higher levels of educational attainment.

Socioeconomic well-being in early adulthood among repeat versus one-time teenage mothers.

Teenage mothers are known to be at elevated risk for poor socioeconomic outcomes in adulthood. However, little is known about the socioeconomic outcomes of mothers who bear multiple children during the teenage years (repeat teenage mothers) compared to one-time teenage mothers. This study examines socioeconomic outcomes in the mid- to late 20s of repeat teenage mothers compared to one-time teenage mothers in a national U.S. sample. Repeat teenage mothers were less likely to graduate high school and more likely to receive public assistance and experience material hardship than one-time teenage mothers in their mid- to late- 20s. Lower educational attainment plus the responsibility of caring for multiple children as a young mother may make it difficult for repeat teenage mothers to secure economic stability. Additional supports may be necessary to improve long-term socioeconomic outcomes of repeat teenage mothers.

Adolescent E-cigarette Users at Highest Risk of Cigarette Smoking Intention.

Objectives: Adolescent e-cigarette users are at risk of developing smoking intention, an established predictor of conventional cigarette smoking. In this study, we identify subgroups of adolescent e-cigarette users who are most likely to intend to smoke conventional cigarettes. Methods: Cross-sectional data on 1357 8th and 10th grade e-cigarette users who had never smoked conventional cigarettes were obtained from 2014-2017 Monitoring the Future Surveys. We conducted latent class analysis to identify subgroups of adolescent e-cigarette users; through latent class regression analysis, we examined the association between subgroup membership and smoking intention. Results: We identified 3 subgroups of adolescent e-cigarette users: socially-protected (56.6%), peer-driven (29.8%), and market-vulnerable (13.6%). The peer-driven class reported the highest number of peers who smoke and the lowest proportion of friends who strongly disapproved of daily cigarette smoking. They were significantly more likely than the socially-protected and market-vulnerable classes to have smoking intention (AOR=2.46; 95% CI 1.84-3.28, and AOR=2.29; 95% CI 1.48-3.53, respectively). Conclusion: Our findings provide insights on the constellation of risk and protective factors that contribute to smoking intention among adolescent e-cigarette users. It highlights peer influence as an important area of emphasis for adolescent smoking prevention programs.

Higher Rates of Twinning Among Repeat Vs First-Time Teenage and Young Adult Mothers in the United States, 2009-2018.

STUDY OBJECTIVE: Few studies examining predictors of twinning consider younger mothers who do not use assisted reproductive technologies (ART). Higher parity is associated with greater odds of having a twin birth, but it is unclear whether this association is present among young women. We tested the hypothesis that the rates and odds of twinning would increase with parity among teenage and young adult mothers who did not use ART. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective, population-based cohort study using 2009-2018 United States National Vital Statistics data on 11,383,370 (58.94% first, 41.06% repeat) births to adolescent and adult women aged 15-24 years. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Rates and odds of twinning by parity among teenage (15-19 years) and young adult (20-24 years) mothers. RESULTS: The adjusted twin birth rate among first-time teenage mothers was 13.28 per 1000 births compared to 16.62 twins per 1,000 births among repeat teenage mothers. This difference by parity was present but smaller among mothers aged 20-24 (18.31 vs 21.44 twins per 1000 births for first-time and repeat young adult mothers, respectively). CONCLUSION: Repeat young mothers, particularly teenage mothers, are a high-risk group in terms of infant and maternal health outcomes; their higher rate of twinning puts them at an additional risk for adverse birth outcomes. Practitioners may counsel young mothers at risk for subsequent unintended pregnancy on elevated risk of twinning.

Mechanisms linking teenage mothers' educational attainment with self-reported health at age 50.

BACKGROUND: Early childbearing is associated with adverse health and well-being throughout the life course for women in the United States. As education continues to be a modifiable social determinant of health after a young woman gives birth, the association of increased educational attainment with long-term health for women who begin childbearing as teenagers is worthy of investigation. METHODS: Data are from 301 mothers in the National Longitudinal Survey of Youth 1979 who gave birth prior to age 19. We estimated path models to assess women's incomes, partner characteristics, and health behaviors at age 40 as mediators of the relationship between their educational attainment and self-rated general health at age 50. RESULTS: After accounting for observed background factors that select women into early childbearing and lower educational attainment, higher levels of education (high school diploma and GED attainment vs. no degree) were indirectly associated with higher self-rated health at age 50 via higher participant income at age 40. CONCLUSIONS: As education is a social determinant of health that is amenable to intervention after a teen gives birth, our results are supportive of higher educational attainment as a potential pathway to improving long-term health outcomes of women who begin childbearing early.

Boredom by Sensation-Seeking Interactions During Adolescence: Associations with Substance Use, Externalizing Behavior, and Internalizing Symptoms in a US National Sample.

During adolescence, sensation seeking is linked to several adverse outcomes including substance use, risk taking, and psychopathology. Recent empirical interest in the construct of boredom has revealed that some similar associations may exist for boredom during adolescence. Both boredom and sensation seeking peak during adolescence, and yet, research on boredom and its interaction with sensation seeking are limited. In a multi-cohort, US nationally representative sample of 8th and 10th grade students from the monitoring the future study, latent-moderated structural equation modeling was used to estimate the association of boredom, sensation seeking, and their interaction, to substance use, externalizing behavior, and depressive affect. Moderation by gender was also tested. Boredom and sensation seeking were both significantly associated with most dependent variables. Significant interaction effects were found wherein individuals high on both boredom and sensation seeking reported the highest levels of depressive affect and externalizing behavior. There were no significant interaction effects for substance use indices. Gender moderation was found for depressive affect. The results of this study demonstrate the generalizability of boredom associations and the significance of boredom by sensation-seeking interactions across multiple mental health domains during adolescence. Prevention efforts that attend to both boredom and sensation seeking may be particularly effective for promoting mental health and preventing externalizing behavior.

Health Behaviors and Prenatal Health Conditions in Repeat Vs First-time Teenage Mothers in the United States: 2015-2018.

STUDY OBJECTIVE: Repeat teenage mothers, those who give birth to a second or higher-order infant before age 20 years, are at elevated risk for adverse perinatal outcomes compared with first-time teenage mothers. The objective of the current study was to compare the prevalence of negative pregnancy-related behaviors and gestational health conditions in the national United States population of first-time and repeat teenage mothers. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective, population-based cohort study using annual US birth data files from 2015 to 2018, N = 799,756 (673,394 [84.2%] first, 126,362 [15.8%] repeat) births to women ages 15-19 years. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Pregnancy-related behaviors (including adequacy of prenatal care and weight gain, sexually transmitted infection, smoking, and breastfeeding) and gestational health conditions (gestational hypertension and gestational diabetes). RESULTS: Repeat (vs first-time) mothers had higher prevalence of negative pregnancy-related behaviors: inadequate prenatal care, smoking, inadequate weight gain, and sexually transmitted infection during pregnancy; they were also less likely to breastfeed. Conversely, repeat teenage mothers experienced lower prevalence of gestational hypertension and gestational diabetes. CONCLUSION: Repeat teenage mothers experienced lower prevalence of physical health complications during pregnancy but engaged in more negative pregnancy-related health behaviors. Negative health behavior in pregnancy can lead directly to poor perinatal outcomes for infants. To prevent adverse outcomes from repeat teenage childbearing, we must ensure access to quality, timely, prenatal and postpartum care so teenage mothers can receive support for healthy pregnancy-related behaviors as well as linkage to highly effective contraception to prevent unintended repeat births.

Smoking Intention and Progression From E-Cigarette Use to Cigarette Smoking.

OBJECTIVES: To investigate whether the prospective association between electronic cigarette (e-cigarette) use and cigarette smoking is dependent on smoking intention status. METHODS: Waves 2 and 3 data of the Population Assessment of Tobacco and Health (PATH) Study, a US nationally representative prospective cohort study of tobacco use. Data were collected in 2014-2015 (wave 2) and 2015-2016 (wave 3) and analyzed in 2019. RESULTS: At wave 2, 12.8% of adolescent never-smokers of conventional cigarettes had intention to smoke and 8.5% had ever used an e-cigarette. At wave 3, 3.2% had ever smoked a cigarette. Both smoking intention and ever using e-cigarettes at wave 2 were positively associated with cigarette smoking at wave 3 (adjusted odds ratio [aOR] = 3.03; 95% confidence interval [CI] = 1.97-4.68, P < .001; aOR = 4.62, 95% CI = 2.87-7.42, P < .001, respectively). The interaction between smoking intention and ever using e-cigarettes was significant (aOR = 0.34, 95% CI = 0.18-0.64, P < .01). Among adolescents who had expressed intention to smoke conventional cigarettes at wave 2, the odds of cigarette smoking at wave 3 did not significantly differ for e-cigarette users and never e-cigarette users (aOR = 1.57; 95% CI 0.94-2.63; P = .08). Among adolescents who had no intention to smoke at wave 2, e-cigarette users, compared with never e-cigarette users, had >4 times the odds of cigarette smoking (aOR = 4.62; 95% CI 2.87-7.42; P < .0001). CONCLUSIONS: E-cigarette use is associated with increased odds of cigarette smoking among adolescents who had no previous smoking intention. E-cigarette use may create intention to smoke and/or nicotine use disorder that lead to onset of cigarette smoking.