Adolescent Health Care: A Practical Guide
Joanne E. Cox
Teen pregnancy, despite consistent declines over the last decade, remains an important medical, social, and public health issue in adolescent health. This chapter discusses the epidemiology of adolescent pregnancy, contributing factors, prevention interventions, the management of the pregnant or parenting adolescent, and the outcomes associated with adolescent pregnancy and parenting. Teen pregnancy presents challenges to adolescent health practitioners at multiple levels in the United States.
Epidemiology of Adolescent Pregnancy
- Teenage pregnancies: There are approximately 800,000 pregnancies/year in females aged 15 to 19 with more than 60% of these pregnancies occurring in 18- to 19-year-old females. Of all births in the United States, approximately 13% are in adolescents, and approximately 31% of all nonmarital births are in teens (a reduction from 50% in 1970). Approximately 51% of adolescent pregnancies result in a live birth, 35% end with an abortion, and 14% end with a miscarriage or stillbirth. Eighty percent of teen pregnancies are unintentional. In females younger than 20 years, 34% will become pregnant at least once. Among all 15- to 19-year olds in the United States, approximately 10% become pregnant each year, and among those who have had intercourse, approximately 19% become pregnant each year. For younger 10- to 14-year-old females, there are approximately 15,000 pregnancies/year (Abma et al., 2004).
- Pregnancy and birth rate trends: The United States has set a national goal of decreasing the rate of teenage pregnancies to 43 pregnancies per 1,000 females of ages 15 to 17 years by 2010. In 2000, the teen pregnancy rate for 15- to 17-year-old females was 48.2. From 1990 to 2004, the birth rate for females aged 15 to 19 decreased 33%, from 62 per 1,000 females to 41.6. For 15- to 17-year olds the birth rate decreased from 38.6 in 1991 to 22.1 in 2004 (Martin et al., 2005; Forum on Child and Family Statistics, 2006) (Fig. 41.1). Likewise, the induced abortion rate which peaked in 1983 at 30.7 decreased to 14.5 by 2000. During the 1960s and 1970s, there was a consistent downward trend in births to teen females that was followed by a temporary surge in teen pregnancies during the mid-1980s (Fig. 41.1). The largest decline in the birthrate since 1970 was in women aged 18 to 19 years (28%), compared with a 19% decline for adolescents aged 15 to 17 years. These declines in teen pregnancies and births have occurred across all 50 states (Ventura et al., 2004).
FIGURE 41.1 Pregnancy, birth, and abortion rates for teenagers 15 to 17 years old. (From National Campaign to Prevent Teen Pregnancy. Fact sheet: recent trends in teen pregnancy, sexual activity, and contraceptive use. Washington, DC: National Campaign to Prevent Teen Pregnancy, 2004. Available at: www.teenpregnancy.org/resources/reading/pdf/rectrend.pdf. Accessed June 19, 2005.)
- In 2003, the birth rate per 1,000 females aged 10 to 14 years was 0.6 live births, less than one half that of 1990 (1.4 per 1,000) and the lowest level since 1946 with 6,661 females aged 10 to 14 years giving birth in 2003. This is a 45% decline for births in this age-group since 1990. Approximately two fifths of the pregnancies among 10- to 14-year olds in 2000 ended in a live birth, two fifths ended in induced abortion, and approximately one in six ended in miscarriage (Martin et al., 2005; Menacker et al., 2004).
- The decline in teen pregnancy is due to both increasing use of effective contraception and decreased sexual activity. Analysis of 1991–2001 national data showed a 53% decline in adolescent sexual experience and a 46% increase in use of contraceptives. Both can be
attributed to interventions and changing social customs that have emphasized abstinence or safe sex (Flanigan, 2001; Santelli et al., 2004). The positive economic climate of the 1990s was also a major contributor to declining pregnancy rates as impoverished teens had more hope for future personal opportunities by remaining in school and working (Centers for Disease Control and Prevention, 2005).
- Ethnicity: There are major differences in birth rates by race/ethnicity, with black and Hispanic females disproportionately experiencing pregnancy compared with whites (Table41.1). The largest decline since 1991 by race was for black women. The birth rate for black teens aged 15 to 19 fell 45% from 1991 to 2003 although Hispanic teen birth rates declined 21% between 1991 and 2003. The rates of both Hispanics and blacks, however, remain higher than for other groups. Hispanic females are most likely to experience birth before the age of 20 (24% versus 8% among non-Hispanic whites) (Alan Guttmacher Institute, 2004).
- Geography: Pregnancy rates vary considerably from state to state. In 2003, North Dakota had the lowest teen pregnancy rate (15–19-year olds) of 42 per 1,000 compared to the highest rate in Nevada of 113 per 1,000. Because of state variability in abortion rates, there is a different distribution of teen births rates which range from a low of 18.1 per 1,000 in New Hampshire to a high of 62.9 per 1,000 in Texas. The National Campaign to Prevent Teen Pregnancy has an excellent analysis of teen pregnancy by age, race, and state available at www.teenpregnancy.org.
- Repeat pregnancy: Of 561,330 births to teens aged 15 to 19 years in 2003, 453,826 were first births and 107,512 were subsequent births. The rate of second births was 4.0 and the rate of third births was 0.5. Repeat pregnancy accounted for 11% of the births to females aged 15 to 17 years and 26% of births to females aged 18 to 19 years. Overall, 27.5% of teen mothers by age 20 had a repeat pregnancy in 1993 compared with 23.5% in 2002 (Martin et al., 2005; Centers for Disease Control and Prevention, 2005).
- Prenatal care: In 2003, 70.2% of teens aged 15 to 19 years began prenatal care in the first trimester compared with only 49% of those younger than 15 years. Adequate prenatal care was lowest in non-Hispanic black teens and was directly proportional to age (Martin et al., 2005).
- Income levels: Teens who give birth more often come from families that have a low income (83%) than are teens who have abortions (61%) or teens overall (38%).
Factors Contributing to Adolescent Pregnancy
- High rates of sexual activity: According to the 2005 Youth Risk Behavior Survey (YRBS) (Centers for Disease Control and Prevention, 2006), 47% of U.S. high school students had engaged in intercourse representing a 13% decline since 1991. One third of high school students had had sex in the last 3 months, which suggests that a significant proportion of teens are currently having intercourse. Males are slightly more likely to be sexually experienced than females, and sexual activity increases with high school grade. For high school males, ever sexually active decreased from 55% in 1995 to 48% in 2005. Among never-married females, for those aged 15 to 17, there was a significant decline in the percentage of sexually experienced; whereas, for those aged 18 to 19 there was no significant change. African-American teens have the highest rates of early sexual activity, followed by Latin and white teens (Table 41.2) (Abma et al., 2004).
In 2005, approximately 91% of males and 83% of females used contraception at their last (most recent) sex. Approximately three out of four teens used a method of contraception at their first intercourse. The condom was the most popular method at first intercourse, with 55% of females and 70% of males using this method at their most recent intercourse (Center for Disease Control and Prevention, 2006). Contraceptive use increases sharply with increasing age at first sex for females. However, only 45% of adolescent males report always using condoms, and condom use actually decreases with age when comparing males 15 to 17 years old with males 18 to 19 years old. Females report less frequent use of condoms during intercourse than males which may in part be due to the fact that many adolescent females are sexually active with older partners (Kaplan et al., 2001). For females, there are sharp differences in contraceptive use by ethnicity. In 2002, 36% of Latino girls used contraception at most recent intercourse, compared with 57% of African-American girls and 72% of white teens (Terry-Humen et al., 2006).
- Physical and sexual abuse: Abusive relationships are common features in the lives of adolescent mothers. Nearly half of teen mothers have reported previous sexual abuse or previous coercive sexual experiences (Boyer and Fine, 1992). Another study indicates that 25% of pregnant adolescents give a positive history of abuse in the year before the pregnancy, and 50% of that group will continue to experience abuse during the pregnancy (Kenney et al., 1997; Parker et al., 1994). Sexual victimization may increase risk of pregnancy. Hillis et al. (2004) showed a direct relationship between childhood adverse events and teen pregnancy.
- Economic concerns: Adolescents who live in poverty face many obstacles that may increase their risk of pregnancy. In one study, 60% of teen mothers lived in families with incomes at or below the poverty level at the time of the birth, and one third of them dropped out of high school before becoming pregnant (Moore et al., 2001). Some researchers hypothesize that living in an impoverished environment leads teenagers to have low perceptions of their life choices and options, leading to a low perceived cost of teenage motherhood. This lack of hope for the present and future translates into overall risky behavior and lack of attention for the consequences. Also, a baby can represent success and hope for the future for teens who have faced economic and educational obstacles (Young et al., 2004).
- Cultural values: Early initiation of sexual activity is not unusual if other family members have a prior history of becoming pregnant during adolescence (Furstenberg et al., 1987). Teen parents often have mothers, sisters, or brothers who were themselves teen parents (East and Jacobson, 2001;
Cox et al., 1995b). In this regard, many adolescents live in communities familiar with adolescent parenthood, so they are less likely to postpone sexual intercourse. Adolescents who live in families with little parental support, little restriction of risky behaviors, and poorly defined goals are more likely to become sexually active and are more likely to become adolescent parents. Other cultural factors that may play a role in an adolescent's decision to become pregnant include peer pressure, early dating, and lack of religious affiliation.
- Psychological factors: Although psychological factors, such as depression, may have some influence on an adolescent's decision to become pregnant, the role of psychological and behavioral antecedents is unclear. Other risky behaviors may be associated with sexual activity. The YRBS revealed that overall 23% of adolescents used alcohol or drugs when having sex (Centers for Disease Control and Prevention, 2006).
- Early puberty: Since the turn of the century, the average age at onset of menarche has decreased approximately 3 months per decade from approximately 16 to 17 years in the late 19th century to 12.4 years at present (Jaskiewicz and McAnarney, 1994). This earlier physical maturation has widened the gap between reproductive capacity and cognitive and emotional maturation and has increased the risk of unintended pregnancy in this age-group.
- Developmental issues: Many developmental characteristics of adolescents, particularly of younger teens, interfere with decision making regarding sexual activity and the successful use of contraceptives. These include a limited ability to plan for the future or to foresee the consequences of their actions and a sense of personal invulnerability (Weinberger et al., 2005).
- Barriers to contraceptive use: Many environmental, social, and psychological barriers interfere with decision making regarding sexual activity and contraception among teens. Significant obstacles to successful contraception include the following:
- Inaccurate information: Many teens have misinformation regarding conception and reproduction. Among other myths, many mistakenly believe that they are too young to become pregnant or that pregnancy cannot occur the first time they have intercourse.
- Accessibility: Many young people want to prevent pregnancy but are unable to because of following factors:
- They lack information regarding available methods.
- They do not know about their legal rights to health care.
- They do not know where to obtain contraceptives.
- They have concerns regarding confidentiality.
- They have concerns regarding cost.
- Services are not readily accessible.
- Contraceptive acceptability: Teens may seek out contraceptive services but often have the following reservations:
- Fearful of specific methods and perceived side effects (particularly the possibility of cancer and weight gain they assume to be associated with oral contraceptives)
- Concerned about contraceptive use affecting their future fertility
- Embarrassed over the acquisition or use of the method
- Concerned that the method might interfere with pleasure
- Partner issues: Many young people are interested in contraception but are often unable to discuss contraception with their partners or their partners refuse to use available methods. Females with significantly older male partners are much less likely to use contraception at last intercourse.
- Intended pregnancy: Some young women do not protect themselves from pregnancy because of a desire to have a baby. This desire may emerge from the following needs:
- To solidify their relationship with their partner or please their partner
- Have someone to love and take care of
- Change their status in their family or assert their independence
- To escape from an abusive home environment by creating their own new family
- To establish their fertility
- Provider problems: Acquiring contraceptive services can be difficult for young people because of the following:
- Clinicians may not address sexuality and contraceptive use with their adolescent patients, who may be too embarrassed to initiate the discussion.
- Some providers are unwilling to prescribe contraceptives for their patients without parental knowledge or consent.
- Some providers are overtly judgmental about sexual activity among their young patients, which discourages discussion of sexual involvement and prohibits dispensing of appropriate education and birth control methods.
Teen Pregnancy Prevention Interventions
Both primary (first pregnancy) and secondary (repeat pregnancy) interventions have been created and evaluated. The
program designs are varied and may be developed by parents, schools, physicians, religious groups, social agencies, and government departments. Successful programs include elements of abstinence promotion, contraceptive information/availability, sexual education, education/school completion strategies, job training, and other youth development strategies such as volunteerism, and involvement in arts or sports. Research strongly supports a two-pronged approach to primary prevention by using methods to delay sexual initiation and by providing contraceptive education and availability if necessary. No research exists that links contraceptive education with increased sexual activity (Kirby, 2001).
Evaluation and Management of The Pregnant Adolescent
When an adolescent presents to a health care facility for reproductive health services or advice, it is important to provide an environment that is welcoming and comfortable for young people. The providers in such facilities must be comfortable with adolescents, and familiar with the common presentations and the initial management of adolescent pregnancy.
Role of the Practitioner
Pregnancy in an adolescent can be a crisis for the teen and her family. The provider is in a unique position to offer guidance and support during this time. This health issue requires the provider to give balanced attention to the pregnant adolescent's medical issues and her counseling needs. The teen should be granted confidentiality as they discuss choices and plans. It is vital that the practitioner be familiar with their state's laws on adolescent confidentiality as they vary considerably from state to state (English and Kenney, 2003). In ideal circumstances, the adolescent's family and her partner need to be considered as a plan is formulated to manage the pregnancy. However, the practitioner must ascertain whether there has been sexual coercion, history of physical abuse, or potential for abuse. The practitioner's intervention is recommended in the following:
- Diagnosis of pregnancy and facilitated decision making
- Open, nonjudgmental service planning
- Management of pregnancy, if the teen chooses to continue the pregnancy
- Preparation for parenthood, if the teen chooses to raise the child
- Referrals for subspecialty services, as needed
- Support if the teen chooses adoption
- Family planning and safe-sex education
Open, nonjudgmental service planning is critical. Despite a provider's personal preferences, the provider needs to counsel the adolescent about her options or refer to a provider who is comfortable with counseling pregnant adolescents. Appropriate referrals for care should be made for adolescents needing services that are not available within the provider's own health program. Timely referrals are important, because some of the choices are only available during the early weeks of the pregnancy.
Common Presentations of Pregnancy in Adolescents
Adolescents may present with various complaints that may suggest early pregnancy. The most frequent objective concern is a missed or an abnormal menstrual period. Others may report abdominal pain, fatigue, breast tenderness, vomiting, or appetite changes. Adolescents with such concerns should be questioned about sexual activity, contraceptive use, and desire for a pregnancy test. Adolescents may need extra time to discuss their concerns and any fears that they may have about a possible pregnancy. A flexible approach can allow adolescents to make healthy decisions for their particular situation.
The development of very sensitive and specific pregnancy tests has significantly facilitated the diagnosis of early pregnancy. Pregnancy tests measure levels of human chorionic gonadotropin (hCG), a glycoprotein that is secreted by invasive cytotrophoblast cells in early pregnancy and implantation. The most sensitive pregnancy test is a radioimmunoassay (RIA) that detects serum levels of the β subunit of hCG as low as 7 mIU/mL. Most urine pregnancy tests will detect hCG when levels exceed 25 mIU/mL, thereby giving a positive test result around the first missed menstrual period. The ease of use, low cost, and high degree of accuracy make the urine pregnancy test an essential component of any adolescent health program.
- hCG levels during pregnancy: It is important for the practitioner to remember that hCG levels change significantly during the course of pregnancy and that the results must be interpreted on the basis of the particular test used (sensitivity and specificity). Serum hCG is detectable 8 days after conception in approximately 5% of women and by day 11 in >98% of women. At 4 weeks of gestation, serum hCG doubling times are approximately 2.2 days, but only every 3.5 days by 9 weeks of gestation. Levels peak at 10 to 12 weeks of gestation and then decline rapidly until a slower rise begins at 22 weeks of gestation, which continues until term.
- Abnormally elevated levels can indicate either a multiple-gestation pregnancy or a molar pregnancy. Anticonvulsants, phenothiazine, and promethazine may increase serum hCG levels.
- Abnormally low levels can indicate a spontaneous abortion or ectopic pregnancy. Low levels may also indicate delayed ovulation or implantation. Diuretics and promethazine can decrease hCG levels.
- hCG levels after pregnancy: Levels gradually decrease after a delivery or abortion and the initial decrease is quite rapid. After 2 weeks, the serum hCG level should be <1% of the level when the pregnancy was terminated.
- Term delivery: Levels should drop to <50 mIU/mL by 2 weeks—undetectable by 3 to 4 weeks.
- First-trimester abortion: Initial hCG levels are much higher. If the abortion is at 8 to 10 weeks and initial hCG levels are >150,000 mIU, then levels at 2 weeks can be 1,500 mIU/mL and detectable for 8 to 9 weeks.
- Types of pregnancy kits
- Immunometric tests: These tests are based on enzyme-linked immunosorbent assay (ELISA) techniques that identify two different antibodies for hCG, making these tests specific for the β subunit of hCG.
There is no cross-reactivity with other hormones. The urine test kits usually provide accurate qualitative response within 5 to 15 minutes and measure hCG levels as low as 5 to 50 mIU/m This can provide positive test results as soon as 10 days after fertilization. These are the most common tests used in most family planning, teen clinics, and women's health clinics. Examples of such tests include Hybritech ICON II, Abbott TestPack +Plus hCG COMBO, Quidel Quick-Vue Semi-Q hCG Combo Test, and Quadratech Q-b HS Dipstrip Check-4 Pregnancy Test.
- Home pregnancy testing (HPT): HPTs are popular because they are convenient, quick, and very confidential. Seventeen percent of college women report that they have used a urine home test at least once. The actual accuracy of home tests is not ideal. HPTs are commonly used in the week after the missed menstrual period. During this period of pregnancy, urine hCG values are extremely variable and can range from 12 mIU/mL to >2,500 mIU/m This variability continues through the fifth week, when values range from 13 mIU/mL to >6,000 mIU/mL. A percentage of urine hCG values during the fourth and fifth weeks are below the sensitivities of detection for common HPTs (range 25–100 mIU/mL). Problems with technique and following instructions may cause inaccurate results. A common error is to perform the home test too early. Therefore, it is important not to make clinical decisions based on a home pregnancy test result (Cole et al., 2004).
- Quantitative β-hCG RIA: This highly sensitive test for specific levels of serum hCG takes 4 hours to complete and is positive 10 to 18 days postconception. However, it has no advantage over the immunometric urine tests for the regular clinical setting. The serum test is expensive. The major use is in identifying an abnormal pregnancy such as ectopic pregnancy, trophoblastic disease, or threatened miscarriage by checking either the doubling time or hCG disappearance over time.
- False-positive and false-negative results
- False-negative hCG test results most often involve urine and are due to misreading or interpretation of color changes. Reasons for a negative test result may include an hCG concentration below the sensitivity threshold of the specific test being used, a miscalculation of last menstrual period (LMP), delayed ovulation, or delayed menses from early pregnancy loss. Elevated lipid and immunoglobulin levels, and low serum protein levels can interfere with the serum test.
- False-positive test results with immunometric tests are very rare but can also occur with laboratory error. Very rarely, pregnancy test results are positive due to hCG production from a nonpregnancy source such as tumors of the ovaries, breast, and pancreas. For this reason, clinical correlation with the laboratory finding is essential. Should the laboratory result be inconsistent with the clinical presentation, it is imperative that the provider verify the pregnancy test, using the more sensitive tests available (Braunstein, 2002).
- The physical examination is also an essential element of the evaluation of the pregnant adolescent. Although the pregnancy test will determine whether the adolescent is pregnant, the pelvic examination will help determine the gestational age of the fetus and will identify any problems that may require immediate attention.
- Uterine enlargement: Uterine enlargement usually indicates the following:
- 8 weeks of gestation: Uterine enlargement detected
- 12 weeks of gestation: Uterus palpated at symphysis pubis
- 20 weeks of gestation: Fundal height at umbilicus. At this point in the pregnancy, fetal movements should be detected, and fetal heart sounds should be audible by Doppler study.
- Other signs
- Softening of the cervix
- Discoloration of the cervix (it may appear purple or hyperemic)
- Uterine softness
Should vaginal bleeding be present or abdominal pain be elicited, it suggests pregnancy complications, such as a threatened abortion or an ectopic pregnancy.
Ascertaining the Gestational Age
Most adolescents will want to know the gestational age of the fetus. Providers should be careful to determine the LMP that was normal. This can be accomplished by asking careful questions of the adolescent regarding their cycles, including any lighter than normal cycles that may represent implantation. Those having regular cycles lasting approximately 28 days are best able to predict the gestational age, which is calculated by counting the weeks since the LMP. A pregnancy wheel can be very helpful for calculating gestational age by dates.
The expected date of delivery (also called the expected date of confinement) can be obtained from the pregnancy wheel or is estimated using the Nägele rule. Add 7 days to the first day of the LMP, subtract 3 months from the month of the LMP, and add 1 year to the calculated date. Physical findings can also be used to estimate gestational age by size as indicated earlier. An ultrasonography will also predict gestational age, although this test has a margin of error of 1 week. If the uterus is smaller than expected by menstrual dates, considerations include error in pregnancy test, ectopic pregnancy, incomplete or missed spontaneous abortion, and fertilization that occurred later than dates suggest. If the uterus is larger than expected, considerations include twins, uterine fibroids, uterine anomaly, hydatidiform mole, or fertilization that occurred earlier than dates suggested.
Alternatives for Pregnant Adolescents and Pregnancy Counseling
Counseling the pregnant adolescent about her pregnancy options is perhaps the most important aspect of early pregnancy management. Providers who offer pregnancy tests should be prepared to provide such counseling and medical assessment including pelvic examination for confirmation of gestational age of the fetus, sexually transmitted disease (STD) screening, and multivitamins prescription with folate supplementation.
Critical elements of counseling the pregnant adolescent include the following:
- An assessment of the adolescent's expectations and desires regarding the possible pregnancy. It is to initiate
this discussion in a private setting, when the provider is alone with the adolescent patient. Some adolescents are very anxious and emotional, whereas others are calm and have begun to formulate a plan for a possible pregnancy. A preliminary assessment of any stressors or safety concerns is useful while counseling the adolescent about her test results. A private discussion allows the provider to offer counseling without distractions, and it permits the provider to consider the adolescent independent of others who are involved with the pregnancy (Klein et al., 2005).
- Support of the partner or concerned adult: The adolescent may be accompanied by a partner or by a concerned adult. In such instances, a provider should offer the patient the choice of including this person during a part of the pregnancy counseling session. If the pregnancy test result is positive, adolescents should be encouraged to seek the support of elders (e.g., parents, grandparents, or other trusted adult). These adults will likely form a “core of support” for the adolescent, should she elect to carry the pregnancy to term or decide to terminate the pregnancy. The adolescent's partner may also share in the decision-making process. It is vital, however, to screen the adolescent for safety in both their relationship and family domains.
- Confidentiality: Adolescents are entitled to confidentiality, although family members sometimes disagree. Adolescents should be reminded that any discussions (in a health facility) remain confidential, unless the adolescent wishes to inform or include others. This allows the adolescent to make her own choices regarding disclosure of the pregnancy. Occasionally, there are mental health concerns, such as the threat of suicide or homicide, or there is a threat of abuse. In such cases, it will be necessary to share information about the pregnancy with other health professionals and with the adolescent's adult caretakers (parents or guardians). The practitioners should familiarize themselves with the medical confidentiality laws of their state particularly in regard to statutory rape, parental consent for termination, and guidelines for judicial bypass (English and Kenney, 2003).
- Nonjudgmental approach: The provider needs to give the opportunity for open discussion when counseling an adolescent about a positive pregnancy test result. The provider should allow the adolescent to express her wishes for this pregnancy, without imposing the provider's personal values on the teenager. A provider who is nonjudgmental will enhance the adolescent's ability to identify the pregnancy option that is most appropriate for the adolescent. Appropriate referrals should be available from the provider that will assist the adolescent in achieving her desired pregnancy outcome.
- Presenting options: The adolescent needs to consider many options for this pregnancy, which include the following:
- Carrying the pregnancy to term and assuming parental responsibility
- Family-centered care for the adolescent and her new baby, thereby sharing child-care responsibility among the baby's extended family
- Placing the baby with adoptive parents after the baby is born
- Terminating the pregnancy (e.g., induced abortion)
Adolescents Assuming Parental Responsibility
This is the most common outcome for pregnant adolescents, yet it is, in many respects, the most difficult commitment to fulfill, because it requires the adolescent to assume long-term responsibility for a baby. A comprehensive care program that is designed to address the health and social needs of pregnant adolescents will offer the adolescent the best opportunity for a good outcome. Essential elements for adolescent-focused prenatal programs include a complement of medical, psychological, social, and educational services; staff knowledgeable in adolescent health; services that are culturally sensitive; continuity of care through the postpartum period; and linkages to mother–infant programs (Cox et al., 2005).
Family-Centered Care for the Adolescent and the Newborn
Because adolescents are rarely able to assume independence after the birth of a baby, the adolescent's family (or community) will usually offer support to the young mother and her child. This allows the adolescent more flexibility and more options for personal development; however, it requires that she abdicate a significant amount of parental responsibility to other family members. Arrangements are unpredictable but may provide (financial and social) stability for the adolescent and the baby. Providers who care for the adolescent parent will need to be linked to community-based services for extended families. Specialized adolescent health services are an essential component of these health programs that reach out to adolescent parents. Such programs offer counseling, health awareness, and parenting classes, in addition to medical care and family planning (Woods et al., 2003). However, long-term continuous relationships with caring providers are essential to positive outcomes (Klerman, 2004).
Adoption after Delivery
Most adolescents who continue their pregnancy intend to raise their baby, although few will express an interest in placing their child in a home with adoptive parents. Few adolescents consider this option at the time that the pregnancy test is obtained, although it is important that the pregnant adolescent be counseled about this option. In most states and the District of Columbia, mothers who are minors may legally place their child for adoption without parental involvement. Fewer than 10% of the babies born to unmarried teens are placed in adoptive homes. Unmarried teen mothers who place their children for adoption are more likely to be white, have higher socioeconomic status and educational aspirations, and be from suburban residences (Mosher and Bachrach, 1996).
Terminating the Pregnancy
Unintended pregnancies account for >90% of pregnancies in 15- to 19-year-olds. Adolescents represent 19% of the approximately 1.3 million abortions that occur each year in the United States. More than half of unintended adolescent pregnancies end in induced or spontaneous abortion compared with 35% of adult pregnancies. The rate of
abortions in the United States has consistently declined across all age-groups since 1990 with a 24% decline in adolescents younger than 20 years.
There are many possible explanations for this trend, such as a decline in the availability and accessibility of abortions nationwide. A recent study showed lower abortion rates in low-density population areas when compared to high-density urban areas (Barbieri, 2004). Abortion is a service that is frequently offered in free-standing clinics that are separate from the more traditional, primary health care programs. Therefore, a referral to another facility is generally required for this procedure. Some adolescents lack the skills to negotiate health services in a health facility that is new to them. This may result in a delay in obtaining an abortion, or the adolescent may fail to have the abortion because she is not timely with her preparations (Cates et al., 2000; Jones et al., 2002).
Providers of patients who seek an abortion should be aware that careful follow-up and psychological support is needed while the adolescent explores this option. Providers need to be open minded and respectful of the adolescent's wishes in such circumstances. Adolescents will also need the support of loved ones who are familiar with the adolescent, such as a parent, an older sibling, or other adult relative. Sixty-one percent of minors who have abortions do so with at least one parent having knowledge of the abortion. Most parents appear to support their daughter's decision to have an abortion (Henshaw and Kost, 1992).
Health care providers should be aware of their state's laws governing adolescents who seek abortion services. Many states require that parents of adolescents play an active role in securing an abortion for their daughter. Careful attention to legal considerations, including the rights of parents, will be important as the provider advocates for the adolescent. Any financial barriers that may interfere with the adolescent's ability to obtain the abortion should also be reviewed.
Adolescents who are certain about their decision to terminate the pregnancy should be encouraged to do so in the early stages of the pregnancy. This will minimize both the complications and the costs of the procedure. Most induced abortions are frequently performed within 8 weeks of conception. Delays will increase the cost, both financial and psychological, for the adolescent and her family.
After a teen has decided to end her pregnancy, she may need help in selecting the best method. There are more options for those who have earlier terminations but adolescents may delay abortion until later than 15 weeks. Methods in the first 12 weeks include vacuum aspiration, curettage, and medical terminations with either methotrexate-misoprostol or mifepristone-misoprostol. Between 12 and 24 weeks, methods include dilation and evacuation, amnioinfusion, and uterotonic/hypertonic techniques. Most teens have a first-trimester abortion and decide between a medical or surgical method.
Choice of Medical versus Surgical Early Abortion Methods
Advantages of the medical method are that it avoids surgery and anesthesia, is less painful, may be easier emotionally, provides the girl with more control, is a more private process, and has less risk of infection.
Disadvantages include bleeding, cramping and nausea, more waiting and uncertainty, extra clinic visit, limited to pregnancies up to 7 to 9 weeks, and risk of methotrexate-induced birth defects if abortion is incomplete.
Types of Medical Methods
First trimester Two new methods in United States include (1) mifepristone (RU-486) with misoprostol or (2) methotrexate with misoprostol.
- Mifepristone-misoprostol: Mifepristone is a progesterone antagonist that is an effective abortifacient. The efficacy increases with the addition of a prostaglandin analog such as misoprostol. The earlier in pregnancy that these are used, the higher the efficacy. In women with pregnancies <7 weeks, approximately 95% have a complete abortion. This decreases to approximately 80% in the ninth week. Bleeding and cramping are common with the method, because the drugs' actions are to induce uterine cramping and bleeding. The technique involves at least three visits:
First visit: Mifepristone 600 mg
Two days later: Misoprostol dose. Some abortions are complete before this visit. If not, two 200-µg tablets are given orally. In those who have not aborted, two thirds occur within 4 hours of the prostaglandin administration. Two weeks later: Checkup to ensure completed abortion. Complications include incomplete abortion and heavy bleeding. There are also infection risks. A recent study reported four deaths from toxic shock syndrome and Clostridium sordelliifollowing medical abortion (Fischer et al., 2005).
- Methotrexate and misoprostol: Methotrexate is a cytotoxic drug that is lethal to trophoblastic tissue and is an abortive agent. When used with misoprostol, the combination is approximately 95% successful in terminating early pregnancies. These regimens involve off-label use of the drug. Several protocols have been developed and all involve at least two clinic visits. Similar to the mifepristone technique, the first visit involves administration of methotrexate. The misoprostol is sometimes given for self-administration at home or at a return visit. There is then a follow-up visit to confirm the termination of pregnancy. Complications include incomplete abortion, infection, and heavy bleeding.
Any clinic or clinician contemplating medical terminations of pregnancy must have availability of both ultrasound dating of pregnancies and surgical backup for incomplete abortions.
Advantages to using the surgical method are—quicker (one visit); more certain; teen can be less involved; can be done under general anesthesia; and continuation of pregnancy is rare.
Disadvantages include invasiveness (need for local or general anesthesia) and small risk of uterine or cervical injury or infection.
Types of Surgical Methods
In the United States, surgical methods are the most common method of termination of pregnancy.
- Vacuum aspiration
- The most widely used and standard first-trimester surgical method
Relatively simple technique requiring small cervical dilation
- May be performed with local anesthesia
- Can be done in an office for up to 14 weeks' gestation.
- Dilation and evacuation
- Most common second-trimester method of abortion.
- Requires more dilation than the aspiration method. Laminaria or other osmotic dilators are often inserted before the procedure to gradually dilate the cervix. This may be a 1- to 2-day procedure.
- Is commonly used for procedures between 13 and 16 weeks, although many clinicians use this procedure up through 20-plus weeks.
- Paracervical or general anesthesia is used before evacuating the uterus.
Medical techniques for second-trimester abortions include hypertonic saline instillation, hypertonic urea instillation, and prostaglandin E2 suppository insertion. These techniques account for less than 1% of all abortions in the United States. Most have been replaced by dilation and evacuation procedures, which are faster, safer, and less expensive.
Abortion Risks and Complications
- Infection (up to 3%): This can be minimized by prior diagnosis and treatment of gonorrhea and chlamydia, as well as by the use of prophylactic antibiotics. Infection due to retained products of conception requires antibiotic treatment and an additional procedure.
- Intrauterine blood clots (<1%)
- Cervical or uterine trauma: Women younger than 17 years have an increased risk of cervical injury. Use of laminaria and skillful technique lowers the risk.
- Bleeding (0.03%–1%)
- Failed abortion (0.5%–1%)
The mortality rate is <1 per 100,000 abortions.
Long-term Postabortion Complications
- Medical: Data relating to long-term complications of abortion do not show major risks. First-trimester abortion with vacuum aspiration does not appear to affect fertility rates or cause future spontaneous abortions.
- Psychological: Although some studies report that teens may consider abortion to be a stressful experience, these symptoms are often short lived and can be mitigated with support before, during, and after the procedure (Biro et al., 1986). In a prospective study of 360 black teenage women from urban family planning clinics, Zabin et al. (1989) found that those adolescents having a therapeutic abortion were more likely to remain in school and were better off economically than those continuing their pregnancy or those having a negative pregnancy test result. Those teens terminating their pregnancy experienced no greater levels of stress or anxiety and were no more likely to have psychological problems 2 years later. The teens obtaining an abortion were also less likely to experience a subsequent pregnancy than either of the other two groups.
Medical Management of The Pregnant Adolescent
Pregnant adolescents, because of increased maternal and fetal risks, require special prenatal management. Prenatal care is a major factor predicting a positive outcome for a teen birth. In 2003, 6.4% of all teens received late or no prenatal care (Martin et al., 2005). Factors associated with adequate teen prenatal care are increased age, a longer interpregnancy interval, partner/social support, and participation in a specialized adolescent pregnancy program. These programs often include a multidisciplinary team of medicine, social work, nursing, and nutrition. Practitioners should note that teens are at risk for inadequate care, so they should make special efforts to ensure early linkages with prenatal providers. Following is a brief guide for the practitioner in important areas of prenatal care for the adolescent patient.
- Initial evaluation: Should include a thorough history, including both a family history of chronic illness and a personal medical history. A drug history for tobacco, alcohol, and substance use is important. A thorough and sensitive discussion regarding the pregnant teen's and her partner's risk for human immunodeficiency virus (HIV) infection should be initiated. Because of young people's reluctance to disclose sensitive information during an initial visit, practitioners should continue to assess a teen's risk status throughout her pregnancy. A complete physical examination and pelvic examination should be performed. Laboratory evaluation should include the following:
- Complete blood cell count
- Blood type and group
- Screening syphilis serology
- Sickle cell test in black patients
- Test for Tay-Sachs disease for Mediterranean or Jewish heritage
- Rubella titer
- Pap smear if they have been sexually active for 3 years
- Gonococcal and Chlamydia test
- Hepatitis B serology
- HIV antibody counseling and testing
- Topics to be covered on successive visits
- Physiology of pregnancy
- Maternal nutrition
- Substance abuse
- STDs and HIV infection
- Discussion and referral to a prepared childbirth class
- Breast feeding and infant nutrition
- Infant care and infant development
- Contraception and sexuality
- Postdelivery care needs
- Ideal weight gain should be 25 to 40 lb.
- See Chapter 6 for specific changes in daily requirements during pregnancy.
- The teen should be advised against dieting during pregnancy.
- A prenatal vitamin supplement should be prescribed.
- Additional iron is required if iron deficiency is diagnosed.
Adolescents consuming <1,000 mg/day of calcium should be given a calcium supplement.
- Prenatal visits: Pregnant adolescents should have visits every 2 to 4 weeks, through the seventh month. Visits are every 2 weeks in the eighth month, and weekly thereafter.
- Psychosocial aspects: It is essential to consider that the pregnant teenager's acceptance of the pregnancy and her relationship with her parents or the father of the child may change during the course of the pregnancy. Several studies have demonstrated increased risk for domestic violence during teen pregnancy. It is important to monitor the teen's psychosocial needs and to intervene appropriately.
- Substance abuse: Because of the serious consequences of substance use for both mother and infant, a thorough assessment of drug use history and current practices is necessary at pregnancy diagnosis and throughout the prenatal period. One large epidemiological study found that adolescents were more likely than adult women to stop alcohol and drug use once pregnancy was confirmed. The following is a list of common substances and their effects during pregnancy.
- Alcohol: Fetal alcohol syndrome including prenatal and postnatal growth retardation; facial dysmorphogenesis (microcephaly, short palpebral fissures, cleft palate, and micrognathia); abnormalities of the central nervous system (CNS); and increased risk of cardiac defects, joint abnormalities, hepatic fibrosis, mental retardation, and learning difficulties
- Amphetamines: May cause malformations
- Cocaine: Increased risk of spontaneous abortion and premature delivery; neurobehavioral deficits in the newborn; increased prevalence of abruptio placentae; increased risk of genital and urinary tract defects including prune belly syndrome, hypospadias, and hydronephrosis
- Heroin: Intrauterine growth retardation; neonatal abstinence syndrome (infant irritability, tremor, convulsions, or poor feeding due to heroin withdrawal); increased risk of hepatitis, HIV, and other infections in the mother
- Lysergic acid diethylamide: Increased risk of congenital abnormalities including hydrocephalus, spina bifida, and myelomeningocele
- Marijuana: Questionable increased risk of birth defects
- Nicotine: Impaired growth; increased risk of spontaneous abortion
- Medications and pregnancy: Medication should be avoided when possible during pregnancy. The following is a list of commonly used drugs and their effects during pregnancy.
- Adrenocortical steroids: Low incidence of cleft palate suspected
- Amphetamines: May cause malformations
- Angiotensin-converting enzyme inhibitors: Prolonged renal failure in neonates, decreased skull ossification, renal tubular dysgenesis
- Anticholinergic drugs: Neonatal meconium ileus
- Antacids: May cause malformations; avoid in early pregnancy
- Acyclovir: Safety unknown; use only under strong indications
- Aminoglycosides: Possible eighth nerve toxicity in fetus
- Cephalosporins: Probably safe
- Clindamycin: None known; caution advised
- Erythromycin: Considered safe
- Erythromycin estolate: Risk of cholestatic hepatitis in mother; avoid during pregnancy
- Isoniazid: Embryotoxic in animals; caution advised
- Metronidazole: May affect chromosomes; avoid during pregnancy if possible, particularly in first trimester
- Penicillins: Considered safe
- Sulfonamides: Hemolysis in newborns with glucose-6-phosphate dehydrogenase deficiency and increased risk of kernicterus in newborns; avoid at term
- Tetracycline: Congenital limb abnormalities, cataracts, decreased bone growth, discoloration of fetal teeth; avoid during pregnancy
- Trimethoprim: Folate antagonist; avoid during pregnancy
- Carbamazepine (Tegretol): Neural tube defects, questionable association with facial dysmorphism, hypoplasia of fingers or toenails, bifida and congenital heart disease
- Diazepam (Valium): Possible risk of cleft lip without cleft palate
- Ethosuximide (Zarontin): Low teratogenic potential
- Phenobarbital: Possible increase in learning difficulties
- Phenytoin (Dilantin): Developmental disturbances appear less than previously reported and anomalies may be genetically linked to epilepsy; hypertelorism and digital hypoplasia reported in higher frequency with use of phenytoin; other problems are more questionable, including intrauterine growth retardation, mental retardation, and developmental delay; craniofacial abnormalities including depressed nasal bridge, ptosis, inner epicanthal folds, and ocular hypertelorism; limb abnormalities (digital and limb hypoplasia); cardiac defects; and hernias
- Valproic acid: Teratogenic in rodents; increased risk of spina bifida if used in first trimester. It also appears that valproate may be related to a significant amount of mental retardation in children born to mothers using the medications during pregnancy as well as other pregnancy complications.
- Antidepressants: The American Academy of Pediatrics' Committee on Drugs recommends careful assessment of the indications for use of psychoactive drugs during pregnancy. Specifically, selective serotonin uptake inhibitors (Prozac, Effexor, Well-butrin) may be associated with a small increased risk for minor anatomical abnormalities. However, rapid withdrawal can have negative consequences physically and psychologically (Kulig, 2005).
- Fexofenadine has not been adequately studied in pregnant women.
- Diphenhydramine and cetirizine are class B drugs with no known complications during pregnancy.
- Antithyroid drugs: Fetal and neonatal goiter and hypothyroidism, aplasia cutis (with methimazole)
- Aspirin: Association with hydrocephalus, congenital heart disease, and hip dislocation; conflicting reports
- Albuterol: No current evidence of abnormalities
- Hypoglycemic drugs: Neonatal hypoglycemia
- Lithium: Ebstein anomaly
- Misoprostol: Moebius sequence
- Nonsteroidal anti-inflammatory drugs: Constriction of the ductus arteriosus, necrotizing enterocolitis
- Phenothiazines: Cleft palate, hypospadias, microcephaly, syndactyly, cardiac malformations, club foot
- Retinoic acid: Severe teratogenic effects causing craniofacial, cardiac, and thymic malformations
- Warfarin: Skeletal and CNS defects, Dandy-Walker syndrome
- The chronically ill adolescent: Pregnancy in chronically ill adolescents presents specific challenges and requires coordination with their specialty care providers. Each illness is associated with specific risks.
- HIV disease: Practitioners should offer HIV counseling and testing to all pregnant teens. Education regarding the risks of perinatal transmission should also be provided. Pregnant women infected with HIV should be referred for appropriate treatment and supportive services. Some women found to be infected may choose to terminate their pregnancy once their HIV status is known. Others will want access to specialized care designed to manage their infection and reduce their risk of perinatal transmission. Because of the risks of HIV transmission through breast milk, breast feeding is not recommended for HIV-infected mothers.
- Battering: Battering often starts or becomes worse during pregnancy. Prenatal risk assessment should include specific questions regarding family and partner violence. Practitioners must be knowledgeable about domestic violence–reporting laws in their state and should be familiar with community resources.
Medical Complications of Pregnancy in Adolescence
Adolescents are not at a higher risk of developing complications during early pregnancy.
- Spontaneous abortion: As with adults, a spontaneous abortion may occur in 20% of pregnancies. A spontaneous abortion occurring in the first 20 weeks of pregnancy usually results from abnormal chromosomal development in the fetus or abnormalities of the pelvic structure in the adolescent.
Abdominal cramping and vaginal bleeding characterize the early stages of a miscarriage, or a spontaneous abortion. The term threatened abortion refers to pregnancies complicated by bleeding and cramping, but the cervix remains long and closed. Should the condition progress, the pregnancy is nonviable and an abortion is considered “inevitable.” Physical changes include a widening of the cervical os and an increase in the bleeding and cramping. A “complete abortion” occurs when all the products of conception have passed. A sonogram will confirm the absence of the fetus, and physical examination will show that cervical os is closed. If the miscarriage is considered an incomplete abortion, a dilation and evacuation procedure will be necessary to prevent blood loss and infection.
- Ectopic pregnancy: Abdominal cramping and bleeding also suggest an ectopic, or extrauterine, pregnancy. An ectopic pregnancy occurs in only 2% of all pregnancies (see Chapter 56).
- Hydatidiform mole, or gestational trophoblastic disease, may occur in 1 of 1,000 pregnancies each year. Although adolescents commonly experience vaginal bleeding and abdominal cramping with a problem pregnancy, those with a hydatidiform mole usually have severe and profuse bleeding. The uterus is larger than expected given the estimated gestational age of the fetus, and the hCG levels are very high. The hCG levels are often >100,000 mIU/m Ultrasonogram of the uterus demonstrates the characteristic cluster of grapes appearance of the mass.
An immediate procedure is needed to terminate a molar pregnancy. Treatment with dilation and suction is the treatment of choice, although the procedure is complicated because it places the patient at increased risk for severe hemorrhage. Close follow-up of the hCG level is required to ensure that the tumor has been adequately removed. The hCG level should remain <2 mIU/mL for 1 year. If the hCG level remains elevated, it suggests that the tumor has not been sufficiently removed; if the hCG level rises, it suggests the tumor has recurred. If the patient has persistent or recurrent disease, she should use a reliable method of contraception for the year after the diagnosis of trophoblastic disease.
Other Consequences of Adolescent Pregnancy
For teens older than 15 years, pregnancies do not have increased risk of adverse outcomes if they receive adequate prenatal care. However, for teens younger than 15 years, there are increased risks, independent of prenatal care, for prematurity, low birth weight, and mortality. Factors associated with pregnancy outcome are variations in prenatal care, nutritional status, prepregnancy weight, STD exposure, smoking, and substance use. Owing to these factors, adolescents are at doubled risk for low infant birth weight and tripled risk for neonatal death.
The children of teen mothers face significant challenges with risks of developmental delay, behavioral problems, school failure, mental health problems, and high-risk behaviors during adolescence. Sons are at increased risk for incarceration and teen fatherhood and daughters are at increased risk for pregnancy; thereby, continuing family cycles of teen pregnancy.
Growth and Development
Although some recent studies have suggested small potential decreases in hip bone mineralization and ultimate height in the very young pregnant adolescents, no definitive data suggest that adolescent pregnancy adversely affects growth and development. Young adolescents (e.g., those younger than 15 years) may not fully understand
the long-term implications of childbirth, particularly in the early stages of the pregnancy.
Fifty percent of adolescent mothers complete high school by 18 years of age, compared with 97% of adolescents who do not get pregnant before finishing high school. By age 35 to 39 years, 70% of adolescent mothers have high school degrees. Factors linked to higher educational attainment for adolescent mothers are race (blacks do better than whites), growing up in a smaller family, the presence of reading materials in the home, mother's employment, and higher parental educational level (Barnett et al., 2004).
Teen parenthood is associated with socioeconomic disadvantage. Teen mothers are more likely to end up on welfare (80% receive assistance at some point in time). An estimated 50% of funds of the Temporary Assistance for Needy Families (TANF) budget is expended on families in which the mother was a teenager when her first child was born. As teenage mothers get older however, many move off public assistance. A recent follow-up study of teenage mothers found that a substantial majority finished high school, found regular employment, and achieved economic independence albeit with lower incomes than women who delayed childbearing into adulthood (Klerman, 2004).
Repeat pregnancy is often targeted by adolescent parenting interventions because short interpregnancy intervals are associated with adverse pregnancy, neonatal, and child outcomes. The rate of second births to adolescent mothers has declined over the last decade. However, within 2 years, 10% to 40% of teen mothers become pregnant again. Protective factors against repeat adolescent pregnancy are older maternal age (>16 years), participation in a specialized adolescent parent program, use of effective contraception, school attendance, new sex partner, and avoidance of interpersonal violence (Klerman, 2004).
Male Adolescents as Fathers
Young fathers rarely receive the same degree of attention and support that is offered to adolescent mothers. Fathers may not be included in decisions regarding pregnancy options, they may not participate in prenatal or childbirth classes, and they may not establish a long-term supportive relationship with the mother of the child.
Whenever possible, the provider should attempt to discuss reproductive health issues with their male patients who are sexually active. This is easily done during health maintenance visits, but it should also be done during visits for evaluation of STDs. Asking the male patient about whether he has fathered a child is reasonable when he indicates that he is sexually active. Supportive counseling should be available to male adolescents who are actively involved with babies they have fathered and to male adolescents who have pregnant girlfriends (Anda et al., 2002).
For Teenagers and Parents
http://www.teenpregnancy.org/. National Campaign to Prevent Teenage Pregnancy, contains a teen sub-site and youth online network.
http://www.siecus.org/pubs/fact/fact0010.html. Fact sheet from SIECUS on teenage pregnancy.
http://www.teenwire.com. On teen pregnancy.
http://www.plannedparenthood.org. General home page of Planned Parenthood that also includes information in Spanish.
http://www.noah-health.org/. Information on pregnancy from NOAH-Health has many other health issues, and available in Spanish.
For Health Professionals
http://www.cdc.gov/reproductivehealth/unintendedpregnancy/. CDC site on teenage pregnancy.
http://www.urban.org/family/invmales.html. From the Urban Institute: Involving males in preventing teen pregnancy.
http://aspe.hhs.gov/hsp/teenp/intro.htm. Department of Health and Human Services (DHHS), a national strategy to prevent teen pregnancy.
http://aspe.hhs.gov/hsp/teenp/. Annual report from the DHHS on teenage pregnancy.
http://www.hhs.gov/opa/titlexx/oapp.html. The DHHS Office of Adolescent Pregnancy Programs.
http://arhp.org. Web site of the American Association of Reproductive Health Professionals.
http://www.agi-usa.org/sections/adolescents/php. Alan Guttmacher Institute (AGI) site with many pages on teenage pregnancy.
http://www.agi-usa.org/pubs/. AGI area on teen pregnancy.
http://www.guttmacher.org/pubs/state pregnancy trends. pdf. AGI pregnancy trends with state-by-state analysis.
http://www.agi-usa.org/pubs/or teen preg decline.html. AGI on why teenage pregnancy rates are declining.
http://www.agi-usa.org/pbs/or teen preg survey.html. AGI study on teenagers' pregnancy intentions and decisions.
http://www.socio.com/. The Data Archive on Adolescent Pregnancy and Pregnancy Prevention (DAAPPP). The DAAPPP was established by the U.S. Office of Population Affairs in 1982 as the repository for the best social science data on the incidence, prevalence, antecedents, and consequences of teenage pregnancy and family planning.
http://www.childtrends.org. Excellent research briefs and facts in at-a-glance sections.
http://www.nlm.nih.gov/medlineplus/teenagepregnancy. html. Excellent index of timely information, a bilingual site from the National Institutes of Health.
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