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
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.)
Factors Contributing to Adolescent Pregnancy
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).
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.
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:
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.
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.
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:
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).
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.
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.
Relatively simple technique requiring small cervical dilation
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
The mortality rate is <1 per 100,000 abortions.
Long-term Postabortion Complications
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.
Adolescents consuming <1,000 mg/day of calcium should be given a calcium supplement.
Medical Complications of Pregnancy in Adolescence
Adolescents are not at a higher risk of developing complications during early pregnancy.
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.
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.
References and Additional Readings
Abma JC, Martinez GM, Mosher WD, et al. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002. National Center for Health Statistics. Vital Health Stat 2004:23(24):1.
Alan Guttmacher Institute. Sex and America's teenagers. New York: Alan Guttmacher Institute, 1994.
Alan Guttmacher Institute. Why is teenage pregnancy declining? The roles of abstinence, sexual activity and contraceptive use. Occasional report. New York, NY: Alan Guttmacher Institute, Available at: www.guttmacher.org/pubs/or teen preg decline.pdf. Accessed November 13, 2005. 1999.
Alan Guttmacher Institute. Teen pregnancy: trends and lessons learned. Available at: www.guttmacher.org/pubs/tgr/05/1/gr050107. Accessed November 13, 2005. 2002.
Alan Guttmacher Institute. U.S. teenage pregnancy statistics: overall trends by race and ethnicity and state-by-state information, 2004. Accessed June 19, www.guttmacher.org/pubs/state pregnancy trends.pdf. 2005.
Alexander CS, Greyer B. Adolescent pregnancy occurrence and consequences. Pediatr Ann 1993;22:2.
American Academy of Pediatrics. Committee on adolescence adolescent pregnancy current trends and issues: 1998. Pediatrics 1999;103:516.
Anda RF, Chapman DP, Felitti VJ, et al. Adverse childhood experiences and risk of paternity in teen pregnancy. Obstet Gynecol 2002;100(1):37.
Bacon JL. Adolescent sexuality and pregnancy. Curr Opin Obstet Gynecol 2000;12:345.
Barbieri RL. Population density and teen pregnancy. Obstet Gynecol 2004;104(4):741.
Barnett B, Arroyo C, Devoe M, et al. Reduced school dropout rates among adolescent mothers receiving school-based prenatal care. Arch Pediatr Adolesc Med 2004;158(3):262.
Berenson AB, Wiemann C. Contraceptive use among adolescent mothers at 6 months. J Adolesc Health 1997;89:999.
Biro FM, Wildey IS, Hillard PJ, et al. Acute and long term consequences of adolescents who choose abortion. Pediatr Ann 1986;15:667.
Boggess S, Bradner C. Trends in adolescent males' abortion attitudes, 1988–1995: differences by race and ethnicity. Fam Plann Perspect 2000;32:118.
Boyer D, Fine D. Sexual abuse as a factor in adolescent pregnancy and child maltreatment. Fam Plann Perspect 1992;24:4.
Braunstein GD. False-positive serum human chorionic gonadotropin results: Causes, characteristics, and recognition. Am J Obstet Gynecol 2002;187(1):217.
Cassell C, Santelli J, Gilbert BC, et al. Mobilizing communities: an overview coalition partnership programs for the prevention of teen pregnancy. J Adolesc Health 2005;37:S3.
Cates W, Grimes DA, Schulz KF. Abortion surveillance at CDC. Am J Prev Med 2000;19(Suppl 1):12.
Centers for Disease Control and Prevention. Health risk behaviors among adolescents who do and do not attend school—U.S., 1992. MMWR Morb Mortal Wkly Rep 1994;43(8):129.
Centers for Disease Control and Prevention. Abortion surveillance: preliminary data—United States, 1992. JAMA 1995;273:371.
Centers for Disease Control and Prevention. National and state-specific pregnancy rates among adolescents—United States, 1995–1997. MMWR Morb Mortal Wkly Rep 2000;49:605.
Centers for Disease Control and Prevention. Effect of revised population counts on county-level hispanic teen birthrates—United States, 1999. MMWR Morb Mortal Wkly Rep2004;53(40);946.
Centers for Disease Control and Prevention. Trends from 1976–2003 in pregnancy, birth and abortion rates in teens 15–17 years, source. MMWR Morb Mortal Wkly Rep2005;54(04);100.
Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2003. MMWR Morb Mortal Wkly Rep 2006;55(SS-5):1.
Cheyne KL. Adolescent pregnancy prevention. Curr Opin Pediatr 1999;11:594.
Cole LA, Khanlian SA, Sutton JM, et al. Accuracy of home pregnancy tests at the time of missed menses. Am J Obstet Gynecol 2004;190(1):100.
Corcoran J. Ecological factors associated with adolescent pregnancy: a review of the literature. Adolescence 1999;34:603.
Cox JE, Bevill L, Forsyth J, et al. Youth preferences for prenatal and parenting teen services. J Pediatr Adolesc Gynecol 2005;18:167.
Cox JE, Bithoney WG. Fathers of children born to adolescent mothers: predictors of contact with their children at 2 years. Arch Pediatr Adolesc Med 1995a;149:962.
Cox J, DuRant RH, Emans SJ, et al. Early parenthood for the sisters of adolescent mothers: a proposed conceptual model of decision-making. Adolesc Pediatr Gynecol1995b;8:188.
Covington D, Churchill M, Wright B. Factors affecting number of prenatal care visits during second pregnancy among adolescents having rapid repeat births. J Adolesc Health1994;15:536.
Darroch JE, Landry DJ, Oslak S. Age difference between sexual partners in the United States. Fam Plann Perspect 1999;31(4):160.
Davies S, Byrn F, Cole LA. Human chorionic gonadotropin testing for early pregnancy viability and complications. Clin Lab Med 2003;23(2):257.
Davies SL, DiClemente RJ, Wingood GM, et al. Relationship characteristics and sexual practices of African American adolescent girls who desire pregnancy. Health Educ Behav2004;31(4 Suppl):85S.
Duncan GJ, Hoffman SD. Teenage welfare receipt and subsequent dependence among black adolescent mothers. Fam Plann Perspect 1990;22:16.
East P, Jacobson L. The younger siblings of teenage mothers: a follow-up of their pregnancy risk. Dev Psychol 2001;37(2):254.
English A, Kenney KE. State minor consent laws: a summary, 2nd ed. Chapel Hill, NC: Center for Adolescent Health and the Law, 2003.
Fischer M, Bhatnagar J, Guarner J, et al. Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion. N Engl J Med 2005;253:2352.
Flanagan PJ, McGrath MM, Meyer EC, et al. Adolescent development and transitions to motherhood. Pediatrics 1995;96:273.
Flanigan C. What's behind the good news: the decline in teen pregnancy rates during the 1990s. Washington, DC: The National Campaign to Prevent Teen Pregnancy, 2001.
Forum on Child and Family Statistics. America's children in brief: key national indicators of well-being 2006. http://childstats.gov. Assessed August 4, 2006.
Foster HW. Taming the tempest of teen pregnancy. Am J Obstet Gynecol 1999;181(suppl):S28.
Foster HW, Bond T. Teen pregnancy—problems and approaches: panel presentations. Am J Obstet Gynecol 1999;181(suppl):S32.
Franklin C, Corcoran J. Preventing adolescent pregnancy: a review of programs and practices. Soc Work 2000;45:40.
Fraser AM, Brockert LE, Ward RH. Association of young maternal age with adverse reproductive outcomes. N Engl J Med 1995;332:1113.
Furstenberg FF, Brooks-Gunn J, Morgan SP. Adolescent mothers and their children in later life. Fam Plann Perspect 1987;19:142.
Geary FH, Wingate CB. Domestic violence and physical abuse of women: the Grady Memorial Hospital experience. Am J Obstet Gynecol 1999;181:S17.
Glei D. Measuring contraceptive use patterns among teenage and adult women. Fam Plann Perspect 1999;31(2):73.
Goldenberg RL, Klerman LV. Adolescent pregnancy—another look. N Engl J Med 1995;332:1161.
Gottlieb BJ. Abortion—1995. N Engl J Med 1995;332:532.
Grimes DA. Adolescent pregnancy prevention programs. Contracept Rep 1994;5:4.
Grogger J, Bronars S. The socioeconomic consequences of teenage childbearing: findings from a natural experiment. Fam Plann Perspect 1993;25:156.
Gutierrez Y, King JC. Nutrition during teenage pregnancy. Pediatr Ann 1993;22:2.
Hamilton BE, Martin JA, Sutton PD. Births, preliminary data 2002. National Vital Statistics Reports, 2003:51.
Hardy JB, Duggan AK, Masnyk K, et al. Fathers of children born to young urban mother. Fam Plann Perspect 1989;21:159.
Hatcher RA, Trussell J, Stewart F, et al. Contraceptive technology, 18th ed. New York: Ardent Media, 2004.
Hausknecht RU. Methotrexate and misoprostol to terminate early pregnancy. N Engl J Med 1995;333:537.
Henshaw SK. U.S. teenage pregnancy statistics with comparative statistics for women aged 20–24. New York: The Alan Guttmacher Institute, 2003.
Henshaw SK, Kost K. Parental involvement in minors' abortion decisions. Fam Plann Perspect 1992;24:196.
Hillis SD, Anda RF, Dube SR, et al. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death.Pediatrics 2004;113(2):320.
Hoffman SD. Teenage childbearing is not so bad after all: or is it? A review of the new literature. Fam Plann Perspect 1998;30:236.
Hughes ME, Furstenberg FF, Teitler JO. The impact of an increase in family planning services on the teenage population of Philadelphia. Fam Plann Perspect 1995;27:60.
Jacoby M, Gorenflo D, Black E, et al. Rapid repeat pregnancy and experiences of interpersonal violence among low-income adolescents. Am J Prev Med 1999;16:318.
Jaskiewicz JA, McAnarney ER. Pregnancy during adolescence. Pediatr Rev 1994;15:32.
Jones RK, Darroch JE, Henshaw SK. Patterns in the socioeconomic characteristics of women obtaining abortions in 2000–2001. Perspect Sex Reprod Health 2002;34(5):226.
Kalmuss DS, Namerow PB. Subsequent childbearing among teenage mothers: the determinants of a closely spaced second birth. Fam Plann Perspect 1994;26:149.
Kaplan DW, Feinstein RA, Fisher MM, et al. Condom use by adolescents. Pediatrics 2001;107(6):1463.
Kaunitz AM, Grimes DA, Kaunitz KK. A physician's guide to adoption. JAMA 1987;258:3537.
Kenney JW, Reinholtz C, Angelini PJ. Ethnic differences in childhood and adolescent sexual abuse and teenage pregnancy. J Adolesc Health 1997;21:3.
Kirby D. Reflections on two decades of research on teen sexual behavior and pregnancy. J Sch Health 1999;69:89.
Kirby D. Emerging answers: research findings on programs to reduce teen pregnancy (summary). Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001.
Kirby DB, Baumler E, Coyle KK, et al. The “Safer Choices” intervention: its impact on the sexual behaviors of different subgroups of high school students. J Adolesc Health2004;35(6):442.
Klein JD. Adolescent pregnancy: current trends and issues. Pediatrics 2005;103:516.
Klerman LV. Another chance: preventing additional births to teen mothers. Washington, DC: National Organization to Prevent Teen Pregnancy, 2004.
Koren G, Pastuszak A, Ito S. Drugs in pregnancy. N Engl J Med 1998;338:1128.
Kulig JW. Committee on Substance Abuse. Tobacco, alcohol, and other drugs: the role of the pediatrician in prevention, identification, and management of substance abuse.Pediatrics 2005;115(3):816.
Landry DJ, Forrest JD. How old are U.S. fathers? Fam Plann Perspect 1995;27:159.
Leland NL, Petersen DJ, Braddock M, et al. Variations in pregnancy outcomes by race among 10–14-year-old mothers in the United States. Public Health Rep 1995;110:53.
Lemus JF. Ectopic pregnancy: an update. Curr Opin Obstet Gynecol 2000;12:369.
Lindberg LD, Sonenstein FL, Martinez G. Age differences between minors who give birth and their adult partners. Fam Plann Perspect 1997;29:61.
Lugaila TA. Marital status and living arrangements: March 1997 (update). Current population reports, P20–506, US Bureau of the Census. Washington, DC: US Department of Commerce, 1998.
Manlove J, Terry E, Gitelson L, et al. Explaining demographic trends in teenage fertility, 1980–1995. Fam Plann Perspect 2000;32:166.
Marianne E. East, Patricia, and Felice. Adolescent pregnancy and parenting: findings from a racially diverse sample. Mahwah, NJ: Lawrence Erlbaum Associates, 1996.
Marsiglio W. Adolescent fathers in the U.S.: their initial living arrangements, marital experience, and educational outcomes. Fam Plann Perspect 1987;19:247.
Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2003. National vital statistics reports, Vol. 54, No. 2, Hyattsville, MD: National Center for Health Statistics, 2005.
Maynard, RA, ed. Kids having kids: a robin hood foundation special report on the costs of adolescent childbearing. New York: Robin Hood Foundation, 1996.
Menacker F, Martin JA, MacDorman MF, et al. Births to 10–14 year-old mothers, 1990–2002: trends and health outcomes. Natl Vital Stat Rep 2004;53(7):1.
Moore MR, Chase-Lansdale PL. Sexual intercourse and pregnancy among African American adolescent girls in high poverty neighborhoods: the role of family and perceived community involvement. J Marriage Fam 2001;63:1146.
Mosher WD, Bachrach CA. Understanding U.S. fertility: continuity and change in the National Survey of Family Growth, 1988–1995. Fam Plann Perspect 1996;28:4.
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, Available at: www.teenpregnancy.org/resources/reading/pdf/rectrend.pdf, accessed June 19, 2005. 2004.
Neinstein LSN. Issues in reproductive management. New York: Thieme Medical Publisher, 1994.
Ness RB, Grisso JA, Hirschinger N, et al. Cocaine and tobacco use and the risk of spontaneous abortion. N Engl J Med 1999;340:333.
Nitz K. Adolescent pregnancy prevention: a review of interventions and programs. Clin Psychol Rev 1999;19:457.
Parker B, McFarlane J, Soeken K. Abuse during pregnancy: effects on maternal complications and birth weight in adult and teenage women. Obstet Gynecol 1994;84:323.
Pastuszak A, Schick-Boschetto B, Zuber C, et al. Pregnancy outcome following first-trimester exposure to fluoxetine (Prozac). JAMA 1993;269(17):2246.
Peplow PV. RU486 combined with PGE1 analog in voluntary termination of early pregnancy: a comparison of recent findings with gemeprost or misoprostol. Contraception1994;50:69.
Polaneczky M, O'Connor K. Pregnancy in the adolescent patient: screening, diagnosis, and initial management. Pediatr Clin North Am 1999;46:649.
Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: findings from the National Longitudinal Study on Adolescent Health. JAMA 1997;278:823.
Richardson KK. Adolescent pregnancy and substance use. J Obstet Gynecol Neonatal Nurs 1999;28:623.
Santelli JS, Abma J, Ventura S, et al. Can changes in sexual behaviors among high school students explain the decline in teen pregnancy rates in the 1990s? J Adolesc Health2004;35:80.
Satin AJ, Leveno KJ, Sherman ML, et al. Maternal youth and pregnancy outcomes: middle school versus high school age groups compared with women beyond the teen years. Am J Obstet Gynecol 1994;171:184.
Singh S, Darroch JE. Adolescent pregnancy and childbearing: levels and trends in developed countries. Fam Plann Perspect 2000;32:14.
Sonenstein FL, Ku LC, Lindberg LD, et al. Changes in sexual behavior and condom use among teenage males: 1988 to 1995. Am J Public Health 1998;88:956.
Stevens-Simon C, Sheeder J. Paradoxical adolescent reproductive decisions. J Pediatr Adolesc Gynecol 2004;17(1):29.
Terry-Humen E, Manlove J. Cottinghams. Trends and recent estimates: sexual activity among US teen. Child Trends Research Brief, http://www.childtrends.org/Files/SexualActivityRB.pdf. Assessed August 4, 2006. 2006.
Ventura SJ, Abma JC, Mosher WD, et al. Estimated pregnancy rates for the United States, 1990–2000: an update. Natl Vital Stat Rep 2004;52(23):1.
Ventura SJ, Freedman MA. Teenage childbearing in the United States, 1960–1997. Am J Prev Med 2000;19:18.
Weinberger DR, Elvevag B, Giedd JN. The adolescent brain: a work in progress. Washington, DC: The National Campaign to Prevent Teen Pregnancy, 2005.
Woods ER, Obeidallah-Davis D, Sherry MK, et al. The parenting project for teen mothers: the impact of a nurturing curriculum on adolescent parenting skills and life hassles.Ambul Pediatr 2003;3:240.
Wolfe B, Perozek M. Teen children's health and health care use. In: Maynard RA, ed., Kids having kids: economic costs and social consequences. Washington DC: The Urban Institute Press, 1996, 181–206.
Young T, Turner J, Denny G, et al. Examining external and internal poverty as antecedents of teen pregnancy. Am J Health Behav 2004;28(4):361.
Zabin LS, Hirsch MB, Emerson MR. When urban adolescents choose abortion: effects on education, psychological status, and subsequent pregnancy. Fam Plann Perspect1989;21:248.
Zabin LS, Sedivy V, Emerson MR. Subsequent risk of childbearing among adolescents with a negative pregnancy test. Fam Plann Perspect 1994;26:212.