Reasons for ineffective contraceptive use antedating adolescent pregnancies: part 2: a proxy for childbearing intentions.

PURPOSE: Compare the relationship between childbearing intentions, maternal behaviors, and pregnancy outcomes in a group of early/middle adolescents versus a group of late adolescents (specifically high school seniors, high school graduates, and GED certificate recipients). METHODS: The reasons given by a racially/ethnically diverse group of 1,568 pregnant 13-18 year olds for not using contraception were used to classify their pregnancies as intended or unintended. Proportion comparison tests and stepwise logistic regression analyses were used to study the relationship between childbearing intentions, maternal behaviors, and pregnancy outcomes. RESULTS: Regardless of age, adolescents who intended to become pregnant conceived in an objectively more hospitable and supportive childbearing milieu than those who conceived unintentionally. This is evidenced by their greater likelihood of having goals compatible with adolescent childbearing, cohabitation with the father of the child, and living in a non-chaotic environment. However, pregnancy planning was not associated with improved compliance with preventive health care recommendations during gestation nor with infant outcomes. As such, the consequences among adolescents with intended pregnancies were negative, as evidenced by a higher rate of smoking, STDs late in gestation, school dropout, and repeat conception. CONCLUSIONS: Like adults, adolescents with intended pregnancies conceived in an objectively more supportive environment than their counterparts with unintended pregnancies. However, this advantage did not translate into better support, healthier maternal behavior during gestation, or improved pregnancy outcomes.

Reasons for ineffective contraceptive use antedating adolescent pregnancies part 1: an indicator of gaps in family planning services.

PURPOSE: Identify new ways to increase the impact of pregnancy prevention interventions on the number of children born to adolescents. METHODS: The study participants, a racially/ethnically diverse group of 1,568, pregnant 13-18 year olds, reported why they had not used contraception at the time of conception. Their explanations were sorted into categories. The frequency with which each category was endorsed, the stability of these endorsements (Kappa statistic), and differences between adolescents who endorsed each category (stepwise logistic regression) were examined at two points in gestation. RESULTS: "Not ready to prevent pregnancy" was the most frequently endorsed category; it was often the only category endorsed. Logistical barriers and misperceptions about the need for contraception were the least frequently endorsed categories. The reasons individual patients gave for not using contraception changed (K < or = 0.4) during gestation. Yet, adolescents who were not ready to prevent conception consistently differed from those who were; they were more apt to be Hispanic, to live in non-chaotic environments with an adult father of the child rather than their parents, and to have goals compatible with adolescent childbearing. CONCLUSIONS: The most expedient way to strengthen the impact of pregnancy prevention programs on adolescent childbearing is to shift the focus of intervention from overcoming logistical barriers and misperceptions about the need for contraception, to helping young women develop goals that make adolescent childbearing a threat to what they want in life. This means intervening actively enough to ensure that goal setting translates into an internal desire to postpone childbearing beyond adolescence.

Age at menarche and first pregnancy among psychosocially at-risk adolescents.

We sought to determine which factors influence the association between menarche and conception among adolescent study participants (n = 1030), who demonstrated an earlier age of menarche than did national samples. Age at first sexual intercourse (coitarche) mediated the relationship between age at menarche and first pregnancy among White girls, whereas gynecologic age at coitarche (age at coitarche minus age at menarche) and age at menarche explained the timing of the first pregnancy among Black and Hispanic girls. Pregnancy prevention interventions to delay coitarche should also include reproductive education and contraception.

Association of conventional goals and perceptions of pregnancy with female teenagers' pregnancy avoidance behavior and attitudes.

CONTEXT: Fostering conventional goals is a key component of pregnancy prevention interventions for teenagers. However, research has not shown whether having goals independently influences sexual behavior, or whether the perception that pregnancy represents an impediment to achieving goals mediates any association. METHODS: In 1999-2001, a racially mixed group of 351 sexually experienced female teenagers who were inadequate contraceptive users completed surveys about goals, the anticipated impact of childbearing on these goals, and protective behaviors and attitudes. Chi-square, regression and two-by-two table analyses assessed associations between goals and perceptions of early childbearing and pregnancy avoidance measures. RESULTS: Three-fourths of respondents had educational or vocational goals. Eight in 10 of these teenagers perceived their goals to be achievable, but fewer than half thought pregnancy would be an impediment to achieving these goals. Teenagers who had goals were more likely than others to have used a contraceptive at last intercourse (odds ratio, 1.9), but controlling for the perception of pregnancy as an impediment eliminated this association. In contrast, considering pregnancy an impediment was associated with an increased likelihood of supporting each pregnancy avoidance measure (2.1-9.6), and of intending to avoid pregnancy and to have an abortion if pregnant, regardless of whether teenagers had goals (8.3-13.8). CONCLUSIONS: Conventional goals appear to motivate teenagers to avoid getting pregnant only if they believe pregnancy will be an impediment. Thus, it may be less important to encourage young women to formulate goals than to ensure that they consider adolescent childbearing a threat to their plans.

Characteristics of adolescent women who stop using contraception after use at first sexual intercourse.

STUDY OBJECTIVE: Identify correlates of contraceptive discontinuation, which if modified, might make teenagers more, not less, effective contraceptors as they age. SETTING: Teen clinic. PARTICIPANTS: Teenagers who used contraception at first intercourse (N = 120). Some "never" used contraception during the 4 months immediately prior to the survey ("contraceptive stoppers"; n = 38). The others (n = 82) did so "always" or "most of the time" ("consistent contraceptive users"). INTERVENTIONS: Questionnaire responses were used to determine univariate and multivariate associations between contraceptive use group and five categories of factors: inability to plan for sex, belief that pregnancy is unlikely to occur, belief that contraceptives are unsafe, inability to negotiate contraceptive use, and lack of desire to remain non-pregnant. MAIN OUTCOME MEASURE: Odds of being a contraceptive stopper. RESULTS: In univariate analyses contraceptive stoppers scored significantly higher on scales that assessed inability to plan for sex, belief that pregnancy is unlikely, and lack of desire to remain non-pregnant. Contraceptive stoppers were also older and more likely to have been sexually active for at least 6 months. In multivariate analyses, those who were sexually active for at least 6 months (odds ratio [OR]: 2.9, confidence interval [95%CI]: 1.1-7.1), those who believed that pregnancy was unlikely (OR: 3.8; 95% CI: 1.7-8.6), and those who lacked the desire to remain non-pregnant (OR: 2.7; 95% CI: 1.4-5.1) were more likely to stop using contraception. CONCLUSIONS: Our findings suggest that teens who use contraception at coitarche stop doing so as they mature sexually because they begin to doubt the necessity and desirability of using contraceptives. Longitudinal studies are needed to determine if such doubts are preventable and if doing so encourages teens to continue to use contraception.

Maternal age and the size of White, Black, Hispanic, and mixed infants.

OBJECTIVE: To clarify the interaction between maternal age and race in the prediction of infant size at birth. METHODS: Birth certificate data was used to study the relationship between maternal age, race/ethnicity, and the size of term, singleton infants born to 91,061 healthy, non-smoking, non-substance using, primigravidas. RESULTS: Maternal race/ethnicity (Black race: OR: 1.95, 95% CI: 1.49-2.56; Hispanic ethnicity: OR: 1.38, 95% CI: 1.19-1.61) and the interaction term, maternal age x race/ethnicity (OR: 1.06, 95% CI: 1.01-1.11) predicted small-for-gestational age (SGA) birth. The strength of the association between Black race and SGA delivery increased and the strength of the association between Hispanic ethnicity and SGA delivery decreased with age (P < 0.001 for trend). Thus, Black and Hispanic teenagers were more likely to have SGA babies than White teenagers (1.7% and 1.6%, respectively compared to 1.2%; P = 0.003). However, Black women who postponed childbearing until their mid-twenties were more likely to have SGA babies than their Hispanic and White counterparts (2.6% compared to 1.2%, and 1.0%, respectively; P < 0.0001). CONCLUSION: The findings suggest that acquired maternal characteristic(s) cause the reproductive health of Black primigravidas to deteriorate and Hispanic primigravidas to improve with age.

Why lightning strikes twice: postpartum resumption of sexual activity during adolescence.

PURPOSE: To describe the circumstances surrounding the postpartum resumption of sexual activity in a cohort of teenage mothers. The goal was to shed new light on the reasons why teenagers who have just given birth put themselves at risk for conception. METHODS: A racially and ethnically diverse group of 267 poor, predominantly unmarried, primiparous, 13-21 year olds was enrolled consecutively at delivery and followed through the third postpartum month. The primary outcome measure was weeks postpartum at resumption of sexual activity, further categorized as protected or unprotected. The analysis controlled for factors thought to influence the postpartum resumption of sexual activity among adult couples and the use of contraception during adolescence. The Kaplan-Meier method was used to estimate the time to end point and Cox proportional-hazards regression analysis to compute relevant relative risks (RR). RESULTS: By the end of the third postpartum month, 58% of the teenagers had had sexual intercourse and the majority (80%) used contraception when they did so. The median time to first coitus, 10.7 weeks, was unrelated to contraceptive use but was significantly shorter among teenagers who lived with their boyfriends (RR: 2.4; 95%CI: 1.7-3.4) and those who delivered prior to term (RR: 2.1; 95%CI: 1.3-3.6). The analysis revealed that the teenagers who did not use contraception at first postpartum sexual intercourse exhibited more theorized risk factors for conception than those who did and those who remained sexually abstinent. CONCLUSIONS: This new empirical evidence that coital activity resumes soon after delivery should dispel the normative belief that contraception is unnecessary during the puerperium. Early contraceptive vigilence may also decrease the frequency and rapidity with which teen mothers conceive, as the differences in the prevalence of teen pregnancy risk factors we uncovered suggest that decisions about using contraception (not sexual intercourse) determine the risk of rapid repeat conception. Teens with live-in boyfriends and premature babies are especially apt to benefit from the new information in this report as they resume sexual activity sooner than their peers and are less apt to use contraception when they do so.

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

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

Paradoxical adolescent reproductive decisions.

OBJECTIVE: To determine why teenagers who say they do not plan to parent if they become pregnant fail to use contraceptives consistently enough to avoid conceiving by default. METHODS: A racially diverse group of 333 inadequately contracepting, nulligravida teens, 45 (13.5%) of whom did not plan to parent if they became pregnant was studied. Participants completed scales assessing traditional teen pregnancy risk factors, deterrents to contraceptive use, expectations about the effect of pregnancy, the desire to remain non-pregnant, and sexual behavior. RESULTS: Teens who said they would not parent if pregnant were less apt to report boyfriends who wanted them to conceive (RR=0.7; 95% CI=0.5-0.9) and deterrents to contraceptive use (RRs around: 0.6; 95% CI: 0.3-0.9) and more apt to anticipate that childbearing would negatively impact their lives (RR: 1.9; 95% CI: 1.6-2.2), to want to remain non-pregnant (RR: 2.2; 95% CI: 1.8-2.4), and to have used contraception at last sexual intercourse (RR: 1.8; 95% CI: 1.3-2.4). In the group that did not intend to parent the only difference between those who had and had not used contraception at last intercourse was their willingness to plan for sexual activity (OR: 4.6; 95% CI: 1.3-16.7). CONCLUSION: This study suggests that further progress toward preventing unwanted teen pregnancies might be made by dispelling the notion that for young, unmarried women, unplanned sexual intercourse is preferable to planned sexual intercourse.

Limb pain associated with an undiagnosed hemoglobinopathy and pseudononcyesis.

Over a 2-month period, a 16-yr-old African-American female presented with recurrent episodes of severe, migratory limb pain. Sickle cell C disease was ultimately diagnosed. She adamantly denied sexual activity but was found to be 28 weeks pregnant. Her limb pain was probably triggered by the metabolic and hemodynamic demands of pregnancy. The case illustrates the importance of thoroughly examining patients with recurrent, unexplained physical complaints.

The Electronic Report on Adolescent Pregnancy (ERAP).

PURPOSE: To create a data management system that: (1) standardizes antecedent, program, and outcome variables relevant to the shared goals of adolescent-oriented maternity programs while allowing users to add variables pertaining to unique aspects of their work; (2) cues providers to physiologic and psychosocial characteristics that predispose teenagers to adverse pregnancy and parenting outcomes, (3) standardizes patient care by guiding providers through adolescent-oriented prenatal, postpartum, and well baby visits, and (4) establishes the infrastructure to collect data from a nationally representative sample of pregnant and parenting teens. METHOD: We adapted a powerful, state-of-the-art relational database framework (Microsoft Access 2000) to create an easy-to-use data management system-The Electronic Report on Adolescent Pregnancy (ERAP)-that requires minimal training to use on a personal computer. RESULTS: ERAP is designed to meet the administrative and analytic needs of adolescent-oriented maternity programs. It consists of six linked core data tables (teen, pregnancy, prenatal visits, child, interconception interval, and interconception interval visits), that allow users to analyze data from these multiple views while preserving the family structure. In addition, the database standardizes methods for collecting and storing the information and automatically computing the variables needed to monitor and evaluate an adolescent-oriented maternity program. Since by adding variables and appending supplementary tables, users can modify the core database to accommodate unique aspects of their programs and/or research, ERAP is also an ideal conduit for translating research findings into clinical practice. Similarly, because ERAP actually structures the care patients receive, the database provides the infrastructure needed to develop and implement best practice guidelines for treating teen-headed families. Finally, the confidentiality of all subject data is assured because ERAP is password-protected and automatically prepares files for batched external analyses by removing personal identifiers. CONCLUSIONS: ERAP provides the infrastructure needed to create a teen-pregnancy databank at the national level and an efficient patient monitoring system at the program level. By standardizing variable definitions and data collection techniques, serving as a repository for data collected at multiple sites, and tracking the multidisciplinary aspects of the care patients receive, ERAP has the potential to facilitate collaboration between adolescent-oriented maternity programs, increase the scientific rigor of teen pregnancy research, and improve the quality of care individual teen-headed families receive by prompting compliance with best practice guidelines.

Is this patient insulin resistant? How much does it matter?

Alex was an obese 10-year-old girl with a family history of type 2 diabetes, hypertension, and perhaps polycystic ovarian syndrome. Her physical examination was significant for a central accumulation of body fat and acanthosis nigricans. Although the laboratory studies indicated that Alex was not diabetic and probably not glucose intolerant, she could be insulin resistant (IR). Should any further evaluation be done? If Alex is IR, what kind of treatment should be offered? The following discussion addresses these questions by reviewing the pathophysiology, diagnosis, and consequences of isolated IR.

Adolescent childbearing ambivalence: is it the sum of its parts?

BACKGROUND: This study was conducted to compare the utility of methods of assessing ambivalent attitudes about childbearing that require deductive reasoning by the subject to methods that do not. The goal was to predict the intent to use a noncoital method of contraception during adolescence. DESIGN: Participants (N=340) in a racially and ethnically diverse population (white 20%, black 25%, Hispanic 55%) completed two scales concerning attitudes toward childbearing-a traditional Likert scale and a scale with positive, negative, and "I go back and forth" response choices. The indication of ambivalence according to these two scales was determined by two methods-averaging item responses and counting the number of midscale responses. Logistic regression was used to study the relationship between ambivalence (by each method) and contraceptive plans. RESULT: Regardless of the scale's format (Likert or back-and-forth) and the scoring method used (averaging or counting), ambivalent adolescents were less apt to plan on using noncoital contraceptives than were nonambivalent adolescents. However, many of the adolescents who were classified as ambivalent by the averaging method chose no midscale responses (26.3% for the Likert scale and 40.5% for the back-and-forth scale), hence they were not classified as ambivalent by the counting method. These adolescents were younger and had lower average scores than adolescents who were classified as ambivalent by both scoring methods. Moreover, adolescents who were classified as ambivalent by both scoring methods were less likely to intend to use noncoital contraceptives than were nonambivalent adolescents, but adolescents who were classified ambivalent by only the averaging method were not. CONCLUSIONS: Childbearing ambivalence predicts contraceptive plans. However, congruent with theories of cognitive development, methods of assessing childbearing ambivalence that require deductive reasoning on the part of the adolescent tend to overclassify adolescents with discordant attitudes as being ambivalent. Avenues of further study are discussed.

Depression, weight gain, and low birth weight adolescent delivery: do somatic symptoms strengthen or weaken the relationship?

OBJECTIVE: To determine if omission of the Center for Epidemiologic Studies Depression Scale (CES-D) items that assess the somatic symptoms of depression improves the psychometric properties of the scale and utility of the CES-D diagnosis of depression for predicting four adverse obstetrical outcomes that have been tentatively linked to maternal depression. METHODS: A cohort of 1684 13-21-year-old participants in an adolescent-oriented maternity program completed the CES-D at enrollment. Chi-square analyses were used to compare the predictive capacity of depression diagnosed by the full CES-D and the 14-item non-somatic subscale of the CES-D. The reliability and construct validity of the two scales were also compared. RESULTS: Removing the somatic component of the CES-D decreased the proportion of adolescents who met screening criteria for depression. However, it did not improve the psychometric properties of the scale. The reliability (Cronbach alpha: 0.87) and construct validity (depressed adolescents were significantly more psychologically stressed and had poorer social support) of the two scales were equivalent. Regardless of the scale used, adolescent mothers who were depressed in the second and third trimesters were at increased risk for inadequate weight gain and both small for gestational age fetuses and preterm delivery (ORs 1.6-1.8). The differences in case definition and predictive capacity were most evident when the CES-D was administered during the first trimester. However, overall effect sizes were nearly identical with the two scales. CONCLUSION: Removing the somatic component does not improve the psychometric properties of the CES-D or the predictive capacity of the CES-D diagnosis of depression for three sentinel obstetrical outcomes. This information should be reassuring to researchers and clinicians as most studies of the causes and consequences of maternal depression during and after pregnancy use the full CES-D scale.

Trends in illness severity and length of stay in inner-city adolescents hospitalized for pelvic inflammatory disease.

BACKGROUND: In 1998, the Centers for Disease Control and Prevention (CDC) changed their guidelines for treatment of adolescents with pelvic inflammatory disease (PID), no longer recommending hospitalization of all teenagers. STUDY OBJECTIVES: (1) To determine the proportion of adolescents with PID who were admitted for failed outpatient treatment after the CDC guideline change. (2) To determine if adolescents admitted for PID after the guideline change needed longer hospital stays and/or were more likely to be "very ill" [as measured by inflammation markers, e.g. fever] or to have tubo-ovarian abscess (TOA) than those admitted before the change. DESIGN: Retrospective chart review SETTING/PARTICIPANTS: All 12-21-year-old females with the diagnosis of PID admitted to an adolescent inpatient unit in an inner-city teaching hospital during a two-year period before [T1=1995-1997 (54 cases)] and after [T2=1998-2000 (91 cases)] the CDC guideline change. INTERVENTIONS: None MAIN OUTCOME MEASURES: Reason for admission (failed outpatient treatment; TOA; or admission at the time of diagnosis of PID); clinical toxicity at admission, and length of hospital stay (LOS). RESULTS: During T2, 22% of PID admissions were for failure of outpatient therapy. However, those admitted after failure of outpatient therapy (n=20) in T2 were less likely to be "very ill" than those who were admitted at the time of PID diagnosis in either T1 or T2 (n=123) [RR:0.30; 95% CI:0.09-0.94]. Mean LOS for females admitted to the adolescent unit with all diagnoses other than PID did not change between T1 and T2 but mean LOS for those diagnosed with PID decreased significantly from 6.3 +/- 3.7 days to 4.7 +/- 2.7 days, respectively (P = 0.002). LOS for PID was longer for younger (<16 years; 8.20 +/- 4.5 days) than older (> or =16 years; 5.0 +/- 2.8 days) girls (P = 0.02) and for adolescents with TOA (7.9 +/- 5.0 days) than for those without (5.3 +/- 2.9 days) (P = 0.05). CONCLUSION: At our medical center, after the CDC guideline change many adolescents with PID were admitted because of failure of outpatient therapy but they were not sicker than those admitted at the time of diagnosis and overall LOS for PID was shorter. These findings are reassuring because they suggest that an initial trial of outpatient therapy for PID is unlikely to harm adolescents and may lead to significant cost savings.